From a medico-legal perspective, medical records should be retained until there is little or no risk of litigation regarding the patient`s treatment. This depends on the statutory statute of limitations period in the respective jurisdiction, and in some jurisdictions this is also affected by specific laws for medical records. Unfortunately, it is difficult to determine with certainty the exact limitation period, as courts generally have the discretion to extend the limitation period in certain circumstances. If there has been a patient complaint, adverse outcome, or legal process, medical records must be retained indefinitely (or obtained from MDA National Advice before disposal). Medical records of a patient with a developmental disability should also be retained indefinitely or for up to seven years after the patient`s death. The ACT, NSW and VIC have set the minimum period for which medical records must be retained, namely: Additional tasks can be added to the Nurse Hub as a reminder. All patient documentation can be entered into flowcharts (observations, water balance, LDA assessment) throughout the shift. Clinical information not captured in flowcharts and changes to the treatment plan is documented as a real-time progress note. It is useful to include headings and, if the report is long, numbered paragraphs in the report. The proposed format for a medico-legal report is as follows: As described above, a treating physician is not obligated to give an opinion in a medico-legal report.
In fact, some opinions may go beyond the expertise of the attending physician. In those circumstances, observations should be refused and only factual information should be provided. Independent medical advice can then be obtained based on the facts and/or medical records provided by the attending physician. Documentation of care is essential for good clinical communication. Appropriate documentation accurately reflects nursing judgments, changes in clinical status, care and relevant patient information to assist the multidisciplinary team in providing excellent care. Documentation serves as proof of care and is an important prerequisite in professional and medical law of nursing practice. Patient assessments are documented in appropriate treatment regimens and must contain the minimum “required documentation”. To ensure that the required documentation is complete for each patient, use the link to the EMR Req Doc advice sheet – coming soon. Medical records can be used as evidence in legal proceedings, including claims for medical negligence, disciplinary hearings, criminal proceedings or corona investigations.
Medical negligence claims can involve a dispute over the facts, which is why complete and accurate medical records are often essential to establish the facts when defending a claim or complaint. In the absence of evidence, the patient`s memory may be preferred to that of the physician, especially if the physician does not fully remember the event or the patient. After receiving a complaint or complaint, you may be tempted to change medical records or record all your memories of the event. This can make a defensible claim untenable. Poor medical records can make it difficult to defend a claim, but altered medical records can make a claim virtually impossible. Once you have become aware of a claim or complaint, no changes of any kind should be made to the medical records. This article is provided by MDA National. They recommend that you contact your compensation provider if you have specific questions about your compensation coverage. Scenarios are based on actual medical negligence claims or medico-legal discharges; However, some facts were omitted or altered by the author to ensure the anonymity of the parties concerned. It is important to know that all opinions expressed in a forensic report are often subject to special scrutiny by the reader of the report and may be publicly reviewed and challenged in court. The weight given to opinion usually depends on the expertise and experience of the author. Nursing documentation is based on the “nursing process” and reflects the principles of assessment, planning, implementation and evaluation.
It is ongoing and the documentation of care should reflect this. Provide a structured and standardized approach to documenting inpatient care. This ensures consistent clinical communication processes across UC. MDA National considers these requirements to be appropriate in all Australian contexts. Electronic health records are becoming more common in medical practice, and physicians often have to deal with the medico-legal and practical issues associated with maintaining a mix of paper and electronic health records. Although current legislation does not specify the format in which a patient`s medical records must be kept, in some cases an original paper document may have medico-legal value in case the document is needed in the trial. However, if retention of original paper documents is not possible for any reason, such as storage limitations, the complete original documentation must be scanned immediately and stored in the patient`s electronic medical record. The original paper documents must then be destroyed securely and confidentially once the scanning and saving of the documents has been confirmed. The digitization must be of sufficient quality to permit the reproduction of a complete and legible printed copy from the electronic copy, if necessary. Continued.
Medical Records: A Medico-Legal Perspective At the beginning of each shift, a “Shift Assessment” is conducted, as described in the Nursing Assessment Guideline. The information required for this assessment is gathered from the transfer, patient submissions, required documentation (safety and risk assessments, clinical observations) and an EMR review and is documented in the appropriate treatment regimens.