Duty of the physician to document

The documentation of a state of illness, its course and its therapy is a doctor's duty.

In many medical malpractice cases, inaccurate documentation opens up the possibility of liability claims against the doctor. The physician then finds himself in the unpleasant situation of having to prove that a (undocumented) fact was factual (for example, whether he conducted a certain examination or the patient described certain symptoms).

The documentation should always go as far as is necessary for a physician to be able to treat the patient with the help of the pre-treatment documents. The documentation includes:

• Anamnesis, diagnosis, examination results, findings, doctor's letters
• therapies and their effects, interventions and their effects
• Consent and clarification
• medical notes and instructions
• Deviations from the standard treatment
• Surgery and anaesthesia
• Complications
• Names of treating doctors, nurses, carers (abbreviations are sufficient)

It is recommended to use the "safest" way for the doctor when documenting the procedure. Consequence: It is recommended to document "more than less

Photo documentation saves time: It is recommended to document findings with meaningful photographs. This saves an enormous amount of time. It is advisable to place one side of the medical record next to the object to be photographed so that the patient number or the patient's name is visible. In the patient file a note " FDoc" or similar should refer to the photo documentation.

Abbreviations or abbreviations facilitate the written documentation. The physician can also develop his own abbreviations. This is permitted as long as the physician himself is still able to restore the abbreviations to their original meaning.

1. Christmann P (2017) Doctor's duty of documentation-what must, what can, what should? Dermatology business letter 13:4