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Risk Matters: What to Keep Out of the Medical Record

At SVMIC, we stress the importance of accurate and timely documentation and for good reason – in the event of a claim or lawsuit, the medical record will be the most important piece of physical evidence.  But, just as important as what to include in the medical record is what not to include.

Only clinically pertinent patient-care-related information should be entered in the patient’s medical record. Documents that do not constitute the official medical record should be kept separate from the medical record and restricted from disclosure. Examples include incident reports, privileged documents, and correspondence with SVMIC. 

Most communications with your attorney are legally privileged and, as such, are not subject to discovery.  Similarly, communications with SVMIC relating to a lawsuit, claim, or even a potential claim may also be privileged.  These communications should be kept separate from the patient’s chart, thereby eliminating the possibility of being photocopied or provided to the opposing party without a court order specifically compelling their production.

The record should contain only facts and objective clinical judgment. Remarks on a patient’s personal characteristics are not appropriate.  Examples of terms or phrases not to use in the record include “Drug-seeking,” “Drunk,” and “Liar/lying.” Finally, billing records and peer review documents should also be kept out of the medical record.

About The Author

Jeffrey A. Woods is the Director of Risk Education in the Risk Education and Evaluation Services Department at SVMIC. Jeff received his Bachelor of Science degree from the University of Tennessee Martin and his Juris Doctorate degree from the University of Tennessee Knoxville. Following graduation, he practiced law in Knoxville for almost 15 years, advising physicians and healthcare providers and defending them in malpractice claims. He is licensed to practice in Tennessee and all Federal courts, including the United States Supreme Court. He is a member of the Tennessee Bar Association.

Jeff joined SVMIC in 2003 and was a Senior Claims Attorney until 2015 when he transferred to his current position.

The contents of The Sentinel are intended for educational/informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and/or change over time.

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