Documentation

Documentation, the contemporaneous recording of a patient’s history, examination, decisions, and care, is both a clinical obligation and, in litigation, a central source of proof. The medical record is frequently the most important evidence of what happened, and the quality of documentation can determine whether a plaintiff or a defendant is able to establish their version of events.

Allegations involving documentation arise in two ways. Inadequate documentation may itself be characterized as a departure from the standard of care, where the absence of a record undermined the continuity or safety of care. Separately, missing, incomplete, late, or altered records can attract an adverse inference, under which a court may infer that the absent material would not have assisted the party that failed to keep or produce it. The standard for adequate documentation is a matter of expert evidence and reflects accepted professional practice.

Posts tagged Documentation analyze Ontario decisions in which the adequacy or integrity of the clinical record was in issue.