"If it isn't written down, it didn't happen." This is a common legal assertion, and right or not by the time a malpractice case is in court it is how things work.
The chart towers above all else as the ultimate source of facts on the case. As time passes, the records become more authoritative than memory regardless which is more accurate.
Here is a short list of key points to improve records:
1) Never alter a record, because this can cost you the case and your malpractice coverge. There are acceptable ways to make a change: a single strike out through which the old entry can be read. Then add your addendum, dated in readable notation.
2) Avoid arguments or disagreements in the records. If they occur, try to find some compromise entry that can be subsequently made, so that they don't remain unclarified and unresolved.
3) Clinical care problems, when they arise, need careful documentation to establish your attention to the patient and your quality of care
. It is wise to document the resolution with a follow-up note, and perhaps demonstrate that the problem is resolved any relevant test. This shows continuing attention to the patient and protects you if the problem re-emerges.
4) Be sure the notes communicate your quality of care because it's the most powerful way to show it.
5) If a case is worrisome or problematic, it can help to have a collaborator, consultant or colleague who documents the extra effort and attention given, as well as the standard of care that you're working within.
6) Placing a supporting article or document that establishes a standard of care in the case or elucidates the reasons for your actions can be a real help.
This provides a framework for your standard of care later.
7) Families are key and need to be considered for how they interact about your care.
They can often get confused, and may not remember clearly what is said. It's wise to document conversations with families in the chart. Have a witness during important communications. Phone calls to distant relatives can be very hard to interpret and remember, therefore a note and perhaps a witness is again helpful.
8) Reconsider notes that are very short, to be sure they communicate the needed facts and your time and attention in the matter.