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Want to know what makes a plaintiff’s attorney lean forward in their chair? Vague documentation. Copy-paste assessments. “Patient non-compliant” with no education documented. No reassessment after pain meds. “Will continue to monitor” with no plan. Late entries that look like clean-up work. In litigation, the medical record becomes the story. If it’s incomplete, inconsistent, or defensive… the narrative writes itself. Chart facts. Chart assessments. Chart patient education. Chart reassessments.
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