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{
    "pk": 15614,
    "title": "Charting Practices to Protect Against Malpractice: Case Reviews and Learning Points",
    "subtitle": null,
    "abstract": "Introduction:\n Medical documentation issues play a role in 10-20% of medical malpractice  lawsuits. Inaccurate, incomplete, or generic records undermine a physician’s defense and make  a plaintiff’s lawyer more likely to take on a case. Despite the frequency of documentation errors  in malpractice suits, physicians receive very little education or feedback on their documentation.  Our objective in this case series was to evaluate malpractice cases related to documentation to  help improve physicians’ documentation and minimize their liability risks.\nMethods:\n We used Thomson Reuters Westlaw legal database to identify malpractice cases  related to documentation. Common issues related to documentation and themes in the cases  were identified and highlighted.\nResults:\n We classified cases into the following categories: incomplete documentation;  inaccurate text; transcription errors; judgmental language; and alteration of documentation. By  evaluating real cases, physicians can better understand common errors of other practitioners  and avoid these in their own practice.\nConclusion:\n Emergency physicians can reduce their liability risks by relying less on forms and  templates and making a habit of documenting discussions with the patients, recording others’  involvement in patient care (chaperones, consultants, trainees, etc.), addressing others’ notes  (triage staff, nurses, residents, etc.), paying attention to accuracy of transcribed or dictated  information, avoiding judgmental language, and refraining from altering patient charts.",
    "language": "en",
    "license": {
        "name": "Creative Commons Attribution 4.0",
        "short_name": "CC BY 4.0",
        "text": "Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.\r\n\r\nNo additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.",
        "url": "https://creativecommons.org/licenses/by/4.0"
    },
    "keywords": [
        {
            "word": "Malpractice"
        },
        {
            "word": "Documentation"
        },
        {
            "word": "liability"
        },
        {
            "word": "Medical error"
        }
    ],
    "section": "Ethical and Legal Issues",
    "is_remote": true,
    "remote_url": "https://escholarship.org/uc/item/4706g1g8",
    "frozenauthors": [
        {
            "first_name": "Summer",
            "middle_name": "",
            "last_name": "Ghaith",
            "name_suffix": "",
            "institution": "Mayo Clinic Alix School of Medicine, Phoenix, Arizona",
            "department": "None"
        },
        {
            "first_name": "Gregory",
            "middle_name": "P.",
            "last_name": "Moore",
            "name_suffix": "",
            "institution": "Mayo Clinic, Department of Emergency Medicine, Phoenix, Arizona",
            "department": "None"
        },
        {
            "first_name": "Kristina",
            "middle_name": "M.",
            "last_name": "Colbenson",
            "name_suffix": "",
            "institution": "Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota",
            "department": "None"
        },
        {
            "first_name": "Rachel",
            "middle_name": "A.",
            "last_name": "Lindor",
            "name_suffix": "",
            "institution": "Mayo Clinic, Department of Emergency Medicine, Phoenix, Arizona",
            "department": "None"
        }
    ],
    "date_submitted": "2021-06-28T21:28:16+01:00",
    "date_accepted": "2021-06-28T21:28:16+01:00",
    "date_published": "2022-03-18T22:09:03Z",
    "render_galley": null,
    "galleys": [
        {
            "label": "",
            "type": "pdf",
            "path": "https://journalpub.escholarship.org/westjem/article/15614/galley/7849/download/"
        }
    ]
}