Documenting the Events

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.