[magnetic]

I found omissions to be particularly interesting too.

For example, I once declined to take a shot after the doctor explicitly told me that it would most likely not yield any benefit, given the response I had from other treatments.

The medical record simply shows that I declined the shot, but not that this was upon strong recommendation from the doctor.

This became an issue later when the provider went back to the records and stated "you were offered this shot and declined". It is technically true of course, but context would tell a slightly different story, and would definitely shift more responsibility towards the doctor.

The doctor was probably right to make this recommendation, but the fact that it is not captured in the records makes me uncomfortable.

[novia]

Half the goal of note taking is not writing down anything that will implicate you in a future legal battle.

[web007]

This statement is very accurate.

The article has an example of the opposite, but equally important oddness of liability. If you don't mark down "XYZ thing is normal" then someone will come back to complain that you didn't find a problem with XYZ when examining them 27 years ago.