One of the challenges in proving a medical malpractice
case is the documented written evidence which is to be presented
to the jury. The more evidence that is documented in writing,
the more credible the claim appears to the jury. Thus, it
is important for patients to document bad medical care as
it occurs. This is true even if a claim is not contemplated
or ultimately filed.
Documenting the events simply refers to the
process of writing down the events while the patient is receiving
the medical care. This documenting process can have multiple
benefits. First, in the context of a medical malpractice claim,
it gives written credibility to the patient's version of events.
Second, even if a medical malpractice claim is not being contemplated,
it helps prevent potential errors.
For instance, if a patient is supposed to receive
a certain dose of medication at a certain time and does not
receive it, the patient's family can remind the nurse or physician
so that dire consequences are not suffered by the patient.
Documenting the times and dosages of medicine administered
to the patient not only helps prevent missing a dosage, but
also can potentially avoid an overdose if the patient already
received the medicine but it had not been documented in his
chart by the nurse.
Documenting the events not only means to keep
a written journal of what is happening as it happens, but
also to ask the nurses and physicians to chart events which
are important. All too often, a health care provider forgets
to write important events in the chart because they were too
busy to do it when the event was happening and by the time
the shift ends, they have forgotten all of the critical details.
Keeping a journal will help remind them of
the events. It may also act as a subtle incentive to timely
and accurately chart the events since they will figure out
that the family is making its own contemporaneous record.
When documenting the events it is important to portray your
actions as an attempt to be helpful and understanding instead
of threatening and second guessing. You do not want the defense
lawyer to be able to argue that you were attempting to "build"
a case against them from the beginning.
Most health care professionals will not mind
a person who keeps a journal to be "helpful" to
the patient and his providers. Always stay calm and do not
insult or interrogate the health care providers. Quietly document,
and gently ask the important questions. At the very least,
taking charge of your own health care decisions could literally
save your life.
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