Clinical Notes and Records

The Importance of Good Patient Information

Healthcare professionals are often rushed from one priority to the next as patients’ needs demands. They have relentless jobs that require outstanding time management skills, so it’s understandable if sometimes the clinical notes and records are hard to read.  However, this may be one of the most important needs for a patient with a personal injury claim.

Keeping clear, detailed and appropriate clinical notes is important to an individual’s personal injury claim. As the treating practitioner, you play an important role in the the personal injury litigation process. The observations and opinions, from before and after an accident, will form the foundation for the cases advanced by both sides of the lawsuit. Additionally, they will form the opinions of any experts retained after the fact. This being so, the essential record of these observations and opinions will come from your clinical notes.

For these reasons, you should ensure that any factual information you note down is legible, accurate, detailed and that the source of the information is abundantly clear. Simple differences in writing could have great impacts on a case. For example, writing 03/04/05 as a date could have three different meanings depending on the reader. Something as small as this could have drastic impacts on the individual’s personal injury claim.

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