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What MUST be included in medical documentation?

Discussion in 'Other Legal Issues' started by OttoReload, Mar 20, 2010.

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  1. OttoReload

    OttoReload Law Topic Starter New Member

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    Back in the day I was a medic in the US Army and during my service I had probably written a couple thousand SOAP (a style of medical documentation) notes. One thing that I have heard many people say is “a medical record is a legal document, if you don’t write it down, it didn’t happen”.

    I have done a lot of research regarding the above statement on line, the public library, and the local law library. I have found numerous references to the same thought process but have failed to find any type of law, code, or decision that states the same intent.

    Is the referenced statement above if fact true? If so how can I prove its validity?

    Also, would that carry over into this situation; a healthcare worker performs a task that outside of their “normal” procedural skill set and fails to document that it was done via “doctors orders” or by some type of agency procedural “standing physicians orders”. What I mean is they did the procedure but failed to document by what authority. Can it then be assumed that they did it on their own accord?

    Thanks for your help - Otto

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