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Patient records

is it illegal to just put in patient record what procedures we preformed with out adding “notes”



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2 Answers

I’m not sure that it’s “illegal” but if a patient, for some reason, sued the doctor, the court would look at chart notes and if it isn’t in the notes, it didn’t happen. So it’s always better to be thorough; not only for lawsuit purposes, but for practitioners and patients. For instance, if a patient doesn’t like the ultrasonic, I chart that so next time I don’t waste time trying it again, just for the patient to become annoyed. And PARQ is a must to be added to chart notes!

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I hate when I see minute chart notes. I was taught to write a book and document all conversations, recommendations, names and flavor of products used to cover yourself in times of dire straits. Pre and post op instructions etc… Do as you were taught in school.

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