Recording Negative Findings
A topic that comes up many times is the subject of recording negative findings in one’s medical records. I would like a nickel for every time a client states that they only record positive findings. Say a patient denies an allergy to penicillin but it is not recorded. The patient is prescribed a penicillin type antibiotic and goes into anaphylaxis. Your chart has no entry as to a penicillin allergy one way or the other. Your position is so much more defensible if the patient had denied any prior allergy to penicillin. This same reasoning can be applied to dozens more scenarios. Help yourself by recording negative findings.
Larry Kobak, Esq.