If it isn't written down, it didn't happen: Don't find yourself in the middle of a legal battle with inadequate medical notes

摘要

It was hectic at the clinic today, and you left for the evening without updating the charts of your last few patients. Oh well. You'll just jot down some notes when you get home or take care of it tomorrow morning. But what if you forget? Leaving justthe smallest bit of information out of a patient's record can leave you stranded later on. Douglas Jack, a lawyer and past president of the American Veterinary Medical Law Association, says the law and the courts are moving toward the notion of an "adverse inference" when it comes to medical records. What does that mean? If it isn't written down, it didn't happen.