by Eugene Glick.

( Charles and I thought it wise to include this chapter for our U.S. collegues; in most countries in the world defensive medicine is not yet nessecary. But also for other reasons we think that accurate documentation is an amelioration of clinic practice)

Nothing is more important than accurate documentation when it comes to a medical/legal defence. All pertinent information should be recorded in a manner that is easily understood, every step should be dated and timed, and the name(s) of the staff in contact with the patient clearly identifiable. Since one of the major accusations leveled at abortion providers in many legal cases is that the patient did not have sufficient time to make an informed decision, proper documentation of the process from the time of the first phone contact will make it easier to show that the patient did. in fact. have ample time to consider her decision. Examples of information that would be nice to have documented on a chart are:

1. when the patient called for an appointment. Save your appointment sheets and note when the patient called for an appointment. Consider noting this information on the patient's chart.

2. when the patient arrived for her appointment and was given the chart to complete. Any additional information or instructions relating to the procedure that are given to your patient at this time should be noted in your protocol. If the patient does not speak or understand English, document whether a translator was used and/or whether printed information was given to the patient in her native language.

3. when the patient was taken for counselling. Your office protocol should describe, in detail, all the information covered in a counselling session. Copies of all material used in your facility should also be in this document including such things as post-operative instructions. Counsellors should note the time the consent was reviewed and signed.

4. when the patient had an ultrasound. The sonographer should be clearly identified.

5. when the physician reviewed the ultrasound and history performed a physical examination and checked with the patient to see if she had any additional questions or concerns.

6. when the procedure was performed. Pick a specific starting point like the beginning of the paracervical block.

7. when the procedure was completed.

8. when the patient was taken to the recovery room.

9. when the patient was discharged and who was with her (how she got home). Your office protocol should document the information, instructions and medication that are given at the time of discharge. It is important to have the patient acknowledge that she has received the above information and medications by initialling a statement on the chart.


1. Review your charts, post-operative instructions and all other patient material at regular intervals (at least on a yearly basis). You may have to enlarge the chart and/or restructure the chart in order to get all the vital points included. (This is one of the most difficult things that a clinic/office may have to do but it is possibly one of the most important. Things change !) Make sure to date all new printings. Ordering very large quantities may save you a few dollars, but may cost you in other ways. Antiquated charts. unchanged for years frequently contribute to an undesirable legal result.

2. Use this reorder time as a reminder to do an in-service for your staff. New people come in, new information may need to be included, and everyone needs an update now and then.

3. Keep copies of the old charts and information sheets. This will help to reffresh your memory of office policy at the time a patient was seen and may be useful if a medical/legal issue arises.

If an emergency occurs that requires hospitalisation or any unusual treatment, it is imperative for you to document every step; date and record the time for all entries. Document every phone call made or attempted and every discussion you have with the doctors, patient, her family or "significant other." It may be difficult or impossible to do this as the events occur, but as soon as possible - preferably on the day it occurred - sit down and reconstruct what happened with a dated and timed sequence. Make it legible and do not cram it into a small space in the chart. Use a separate piece of paper if necessary and add it to the chart in a permanent fashion. You should be able to show that the entry was made when the details were still fresh in your mind and not weeks or years later. If the physician should die before the case gets to court, the ability of the clinic to defend itself is sorely compromised without the physician's documentation being available.

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last revised spring 2010