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If You Didn't Chart It, You Didn't Do It

Malpractice cases often hinge on the quality of the medical documentation related to the care of the plaintiff.

Solid medical documentation shares several qualities. It is straightforward, consistent, in chronological order, and reasonably complete. If the doctors and nurses involved in a case documented it properly, they should have an easy time refuting any malpractice claims that arise from that case by showing how their care met acceptable standards.

Things get interesting, though, when the documentation in a case is not well-kept. One common refrain heard in hospitals and medical malpractice courts across the country is, “If you didn’t chart it, you didn’t do it.” What often happens in real-world medical situations is that an emergency, such as hemorrhaging or a heart attack, takes priority over record-keeping. This leads to gaps in the patient file. In a perfect situation, a nurse records the necessary notes once the emergency passes, but busy or overworked nurses may not always remember to do so.

When such gaps appear in documentation, opportunity appears for the plaintiff. Their attorney may well be able to use poor documentation to advance theories that missing information indicates negligent or substandard care.

Malpractice defense attorneys often attempt to head off these attacks in cases where the documentation is obviously subpar. They usually do so by directly examining the nurse and having him or her testify how impossible it is to record every last detail regarding the care of a patient, or to testify about standard hospital practices, which may or may not end up recorded in documents.