Follow John Linkedin Twitter Facebook
Email John Email
Legal Issues
Jul 15, 2016

The Legal Significance Of Good Record Keeping By Professionals

Sponsored Content provided by John Martin - Professional Liability and Medical Malpractice Defense Attorney, CSH Law

Most professionals who are defendants in a lawsuit will soon learn that the success of their litigation could rise and fall on the quality of their record keeping. The differences of opinion will turn on what was intended by the notations in the professional records versus what the notations actually reflected.  At trial or even before a professional licensing board, a legal defense team may have difficulty convincing a jury that just because an action was not recorded, the action still occurred.
 
For health care providers, medical records of patients’ care will become the subject of heightened scrutiny in a trial for health care provider liability. One medical expert testified during a recent trial that physicians keep medical records so that other providers can track a patient’s care, but that the records were not kept for the purposes of satisfying lawyers at trial.  Despite the truth in his statement, good record keeping will not only improve accountability on the job, but it may help win a trial. Further, while poor record keeping is a common accusation against medical professionals, other professionals like accountants are just as accountable for their record-keeping practices.
 
No matter what the profession is or whether records are paper, electronic, handwritten, clinical notes, emails or letters, the most common record-keeping mistakes outlined below, if avoided, could make the difference at a trial for professional liability.

  • Lack of clarity such as “patient had a good day” or “patient slept well”
  • Failing to record an action taken once a problem is identified and recorded
  • Missing information such as failing to record administering a drug
  • Inaccurate records such as recording treatment that was not received
  • A misplaced comma or period in writing a dollar amount, which could lead to an unintended windfall
  • Failing to record conversations or agreements
  • Making record notations too long after the action was taken so that items are forgotten
  • Failing to define key terms or conditions in a contract
Avoiding these record-keeping mistakes may not avoid a law suit entirely, but good record-keeping practices could convince a jury or a professional board that the services rendered were just as good as the records reflect.

John D. Martin is a trial lawyer and the managing partner of the Cranfill Sumner & Hartzog LLP’s Wilmington, North Carolina office. Martin concentrates his practice in the medical malpractice and professional liability defense practice groups.  He has tried numerous medical malpractice and personal injury cases throughout eastern North Carolina. Many of his cases involve brain injury, birth trauma, paraplegia and wrongful death. Additionally, Martin has experience with large construction litigation, premises liability and hospital/workplace security. To contact Martin, call (910) 777-6018 or email him at [email protected]
 

 
            
 

Wbj insights revised 0510 6291692911
Ico insights

INSIGHTS

SPONSORS' CONTENT
Burrus rob headshot 300x300

UNCW Cameron School Of Business MBA Students Work In The Healthcare Industry Through COVID

Robert Burrus - Cameron School of Business - UNC-Wilmington
Tommytaylor ceo unitedway

Hope Is Not Quarantined

Tommy Taylor - United Way
Brochurepicture 7312020434

Five Money Myths To Ignore

Creighton Hayworth - Ameriprise Financial

Trending News

Wilmington Company Acquired By McKim & Creed

Cece Nunn - Oct 26, 2020

State Legislators Voice Opinions On Port Project

Christina Haley O'Neal - Oct 26, 2020

In The Current Issue

Health Care Heroes: Community Outreach

The Community Outreach category honors an individual or team who communicated to the community about a health issue, including treatments an...


Connect Focus: Social Justice

Cucalorus is shifting its Connect Conference to focus more on conversations around pressing social issues and less on technology....


2020 Health Care Heroes Finalists

The Greater Wilmington Business Journal has put on the Health Care Heroes awards program since 2013 to honor the people and organizations ma...

Book On Business

The 2020 WilmingtonBiz: Book on Business is an annual publication showcasing the Wilmington region as a center of business.

Order Your Copy Today!


Galleries

Videos

2020 Leadership Accelerator: Virtual Workshops for Real Leaders
2019 Health Care Heroes
August 26, 2019 Power Breakfast: A Healthy Sale?
2019 WilmingtonBiz Expo Keynote Lunch - CEO, nCino, Pierre Naude`