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    Lessons learned from reviewing malpractice cases

    Over the last 25 years, I’ve seen more than 50 lawsuits come across my desk.

    Before you draw the conclusion that I’m either a terrible physician or have litigious patients, let me explain. 

    Early in my career, I was given the opportunity to sit with a malpractice lawyer, who taught me the best practices for preventing lawsuits. He would hand me a chart, ask me what was right or wrong with it and if I saw any medical malpractice involved. I reviewed chart after chart, looking for subtle items that either supported the documentation, or those items that were lacking or would cause a conflict with what a physician noted.

    I currently serve as a medical expert. Throughout my career, I’ve applied the knowledge I’ve gained reviewing medical records for medical malpractice lawsuits. I have reviewed cases for both the plaintiff and the defense. I continue to learn from each case I review.

    Some of the lessons that I pass onto students—and to fellow physicians—from the cases I’ve reviewed, include:

    Document, document and document some more. If it isn’t documented, it wasn’t done and there is no going back once that note is closed. So dot your “i”s and cross your “t”s before you move on to another note. For those using paper records, make sure all entries are legible. For those using electronic health records (EHRs)—and even those who aren’t— make sure your documentation is complete and accurate. 

    In your EHR, do not clone notes (i.e. “copy and paste”). It will get you into trouble every time.

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