Medical Records 101
What is the medical record?
The four elements of negligence are duty, breach, causation, and this.
What is harm (or damages)?
The general statute of limitations for medical negligence in California.
What is 3 years from the date of the wrongful act?
What are words that imply fault or blame?
This team should be notified after a workplace safety incident.
What is SWIT (Safe Workplace Intervention Team)?
The two qualities your documentation must have to help avoid litigation.
What are accuracy and completeness?
This element of negligence is synonymous with breaking the "standard of care."
What is breach of duty?
The statute of limitations for a minor under the full age of six.
This should be avoided when describing a product malfunction.
What is speculation of cause or subjective details?
This should be completed after a reportable event, but not charted.
What is an incident/safety report?
This is determined by conclusion about the faces, which are reconstructed from the evidence.
What is the outcome of a lawsuit?
This is the primary event that triggers malpractice litigation.
What is patient injury?
This must be commenced within 6 years after the date of birth.
This type of entry should be dated and timed if made after the fact.
What is a late entry?
What is an addendum or clarification note?
This term refers to the accepted level of care expected from healthcare professionals?
What is the standard of care?
This legal concept previously used to define standard of care.
What is custom?
This document should not be mentioned in the patient chart after an incident.
What is an incident report?
This is the best way to describe assumptions about a patient's motives.
This should never be kept at home, especially if it identifies a patient.
What are patient notes/charting/medical records/brains?
This type of opinion is required to support a standard of care defense.
What is an expert opinion?
This group decides whether a deviation from custom was unreasonable.
What is a jury?
This action can extend the stattue of limitations by 90 days.
What is filing a Notice of Intent (NOI)?
This should be preserved and resported if it may be defective.
What is a medical device or product?
This can be your best friend or your worst enemy.
What is medical documentation?