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The Process-of-Care Playbook
A practical, physician-focused deep dive into the documentation habits that can either narrow or expand malpractice exposure. Using a concurring appellate opinion as the framework, this episode examines three recurring process-of-care vulnerabilities—stale risk assessments, orders without documented reasoning, and chart gaps that leave care indefensible—and translates them into concrete next-shift documentation strategies. The core message is straightforward: in modern malpractice litigation, the chart is not just a record of what happened; it is the evidence of whether your clinical judgment can be defended.
SOURCES
* Candello/CRICO. “For the Record: The Effect of Documentation on Defensibility and Patient Safety.” Benchmarking Report. November 2024.
* Kusumoto FM, Ross J, Wright D, Chazal R, Anderson RE. “Analysis of Closed Claims Among All Medical Specialties.” Risk Management and Healthcare Policy. 2024;17:411-422.
* Padula W, et al. “Value of hospital resources for effective pressure injury prevention.” BMJ Quality & Safety. 2018;28:132-141.
* Lorente-Granados G, et al. “Hospital-Acquired Pressure Injuries: Application of Preventive and Reactive Measures in Real Practice.” J Adv Nurs. 2025.
* Pascall E, et al. “Litigation associated with ICU treatment in England.” Br J Anaesth. 2015;115(4):601-7.
* Corum L. “Medical Malpractice in Wound Care: A Multiple Case Series.” J WOCN. 2025;52(5):417-420.
* Ghaith S, et al. “Charting Practices to Protect Against Malpractice.” Western Journal of Emergency Medicine. 2022;23(3):412-417.
* Sharma S, McKenna MK, Brenner MJ. “The Evolving Legal Standard for Medical Malpractice.” Otolaryngology–Head and Neck Surgery. 2025;173:1028-1030.
* American Law Institute. Restatement of Torts — Medical Malpractice. Approved 2024, published February 2025.
* ProAssurance Risk Management Case Study: Documentation and Prevention Protocols.
* VerdictSearch database analysis: 141 pressure ulcer malpractice cases. Published in Adv Skin Wound Care.
* CMS F-686: Treatment/Services to Prevent/Heal Pressure Injuries.
* NPIAP. Unavoidable Pressure Injury White Paper.
DISCLAIMER
This podcast is produced for educational purposes only and does not constitute legal or medical advice. The content reflects publicly available case information, published medical literature, and general legal principles. Laws vary by jurisdiction. Clinical decisions should be based on individual patient circumstances and current evidence-based guidelines. If you are facing a malpractice claim, consult a qualified attorney in your jurisdiction.
This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thecharteddefense.substack.com/subscribe
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By The Charted DefenseA practical, physician-focused deep dive into the documentation habits that can either narrow or expand malpractice exposure. Using a concurring appellate opinion as the framework, this episode examines three recurring process-of-care vulnerabilities—stale risk assessments, orders without documented reasoning, and chart gaps that leave care indefensible—and translates them into concrete next-shift documentation strategies. The core message is straightforward: in modern malpractice litigation, the chart is not just a record of what happened; it is the evidence of whether your clinical judgment can be defended.
SOURCES
* Candello/CRICO. “For the Record: The Effect of Documentation on Defensibility and Patient Safety.” Benchmarking Report. November 2024.
* Kusumoto FM, Ross J, Wright D, Chazal R, Anderson RE. “Analysis of Closed Claims Among All Medical Specialties.” Risk Management and Healthcare Policy. 2024;17:411-422.
* Padula W, et al. “Value of hospital resources for effective pressure injury prevention.” BMJ Quality & Safety. 2018;28:132-141.
* Lorente-Granados G, et al. “Hospital-Acquired Pressure Injuries: Application of Preventive and Reactive Measures in Real Practice.” J Adv Nurs. 2025.
* Pascall E, et al. “Litigation associated with ICU treatment in England.” Br J Anaesth. 2015;115(4):601-7.
* Corum L. “Medical Malpractice in Wound Care: A Multiple Case Series.” J WOCN. 2025;52(5):417-420.
* Ghaith S, et al. “Charting Practices to Protect Against Malpractice.” Western Journal of Emergency Medicine. 2022;23(3):412-417.
* Sharma S, McKenna MK, Brenner MJ. “The Evolving Legal Standard for Medical Malpractice.” Otolaryngology–Head and Neck Surgery. 2025;173:1028-1030.
* American Law Institute. Restatement of Torts — Medical Malpractice. Approved 2024, published February 2025.
* ProAssurance Risk Management Case Study: Documentation and Prevention Protocols.
* VerdictSearch database analysis: 141 pressure ulcer malpractice cases. Published in Adv Skin Wound Care.
* CMS F-686: Treatment/Services to Prevent/Heal Pressure Injuries.
* NPIAP. Unavoidable Pressure Injury White Paper.
DISCLAIMER
This podcast is produced for educational purposes only and does not constitute legal or medical advice. The content reflects publicly available case information, published medical literature, and general legal principles. Laws vary by jurisdiction. Clinical decisions should be based on individual patient circumstances and current evidence-based guidelines. If you are facing a malpractice claim, consult a qualified attorney in your jurisdiction.
This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thecharteddefense.substack.com/subscribe