Medical Documentation and Its Legal Implications The medical record is a valuable legal document. A complete medical chart facilitates medical review solutions including medical chart review.
Documentation is an indispensable component in the legal system, and the failure to document relevant data is regarded as a major breach of and deviation from the accepted standard of care. Accurate documentation in clinical care, as a medical review company serving personal injury lawyers knows, is important both from the point of view of protection from legal consequences and from that of patient care and quality assurance. It is important therefore that the medical record is complete in every respect. What are the risks involved in an incomplete medical record? •
It is proof that the care provided was insufficient/incomplete
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