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COPYRIGHT 2005 International Medical News Group
As important as it is to communicate, communicate, communicate, it also is important to document, document, document.
It simply isn't enough to record "normal for all" or to list only positive findings on a patient's records.
I have worked as a medical malpractice defense expert for many years, and I often hear the excuse that "I only record positive findings."
The problem with that philosophy of documentation is that somewhere in the patient's medical chart, there likely will be a note about "normal ears" or "heart without murmur," or the like, which obviously are normal findings. So, the excuse about recording only pertinent positives is negated. It is far easier to document all the pertinent positives observed in a patient as well as the negatives to demonstrate that you have fully evaluated the patient.
An easy way to do this is to employ a check box for each system. I would avoid a single box of "check here if all are normal" because it still leaves open the question of whether you really examined the genitalia for a child complaining of an earache. Better to check each system's box and write in--or check...
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