Some patients and their families mistakenly believe that any poor medical outcome is a result of medical malpractice. But as medicine is not an exact science and all procedures carry some risk, it is a false assumption to try to link every bad patient outcome to an act of malpractice.
Allegations of malpractice may arise regardless of their veracity. One way to minimize the risk of malpractice is for those in the medical profession to be scrupulous about documenting patient histories and accurately charting events.
Medical records are inviolable
Cases can rise and fall on what lies between the folds of a patient’s chart. The standard of care SOAP (Subjective, Objective, Assessment and Plan) method might not withstand the scrutiny of a jury — or even a peer review.
Since you cannot make changes to a patient’s chart after the fact, it is prudent to be proactive while taking histories and charting.
Present an objective medical record
Subjectivity can lead you into dangerous territory. If a doctor notes during a physical examination that the patient has several tattoos, it would appear pejorative to note that they were White supremacist tattoos. However, it is factually correct to state the patient had a swastika tattoo on their back.
Protect yourself with initialed chart notes
When examining a patient’s private parts, include a qualified assistant in the room. Later, have the assistant initial the chart note, “Medical assistant X chaperoned exam,” thus indicating their presence in the room during the exam.
If your patient’s records get subpoenaed
Many doctors face unfounded malpractice claims, but if it happens to you, take it seriously. Now is not the time to go it alone. You will need to shore up your defense with witnesses in your field who can corroborate that your plan of care was indeed correct given the patient’s medical status.