Medical documentation: the first shield of protection for the doctor before the patient

In the world of medical practice, medical documentation is not just a means of organizing files or facilitating follow-up. It is also

What is medical documentation?

Medical documentation is the process of recording all information related to a patient's condition, including health data, visits, diagnoses, prescriptions, medical procedures, tests, examination results, and treatment recommendations, in addition to the patient's signature approving the treatment plan or agreed-upon procedures.

This documentation is carried out either in paper form or electronically via medical record management systems (such as “My Records”) that have become an integral part of modern healthcare institutions.

Documentation as a means of protecting the physician

In cases of medical complaints or legal claims,

• Whether the doctor performed the appropriate procedure.

• Has the patient been informed of all the details and risks?

• Was informed consent obtained?

• Was the follow-up accurate and regular?

With

• He made his decisions based on clear information.

• Adhere to professional and ethical standards.

• The patient gave full understanding and consent.

Examples of situations where documents protect the doctor:

1. Claim of Misdiagnosis

2. Objection to a medical procedure

3. Delay in treatment

How is documentation effective?

For documentation to fulfill its protective role, it must be:

• Comprehensive

• Regular

• Precise

• Neutral

a summary

Medical documentation is not just an administrative procedure; it is a fundamental legal and professional defense weapon for a physician