Abstract
Eye surgeons have requested risk management advice about documentation of ophthalmic care in course evaluations and needs assessments. A complete, legible medical record serves many purposes. First, it promotes patient safety and continuity of care by providing a comprehensive account of the diagnosis and treatment of the patient’s ophthalmic condition. In the event of a claim or lawsuit, the documentation in the medical record becomes evidence that can be used to defend, or possibly assail, the ophthalmologist’s care.
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