Proper Medical Charting Is Critical to Protecting Against Legal Risk

If you represent medical providers for long enough, you have likely heard the timeless adage posited by the plaintiff's bar "if you didn’t chart it, it didn’t happen." While this phrase is commonly used in medical training to push providers to strive for better documentation and should be at the forefront of any discussion regarding patient care and safety, it also highlights issues that can arise from documentation shortcomings in the legal arena.

In our modern world, most major health care systems have transitioned from handwritten paper charting to a completely electronic-based system. Electronic medical records are now a ubiquitous part of the overall landscape of healthcare in this country, making patient records more accessible than ever.