Legal implications of medical documentation

Abstract

Medical documentation is not only used to ensure continuity of the patient’s care and as a bridge of communication between health professionals. Medical documentation is also very important in medical malpractice and medical negligence cases. This term paper aims to analyse the legal implications of medical documentation in liability cases against medical professionals and how they worked in favour or against the medical professionals. The study is focused on case-law and therefore the author analysed cases from the US, the UK and Malta. This has been done to compare the court’s reasonings from different jurisdictions. Research includes identifying various types of medical documentation and the legal actions and consequences a medical professional may face. The research also touched upon the difference between medical malpractice and medical negligence. Ultimately, this term paper should determine the importance of medical documentation in legal issues and the weight it has on the court’s judgements. The intention of this term paper is to identify the negative issues and how the medical professionals can avoid doing such mistakes which will result in being found liable; and to identify the positive issues which resulted in the medical professionals being cleared of medical negligence or malpractice.