If an item is not charted in a health record, what is the presumption made?

The presumption that "it wasn't documented, it wasn't done" is foundational in healthcare documentation and practice. In the realm of healthcare, proper and thorough documentation is critical for a number of reasons, including continuity of care, legal protection, and the ability to provide evidence of services rendered.

When a healthcare provider fails to document an item in a patient's health record, it typically leads to the conclusion that the item was not addressed at all. Documentation serves as a legal record of care—if something is absent from the record, it can be interpreted that it never occurred. This is particularly significant in legal contexts, where lack of documentation might hinder the provider’s ability to defend the care or treatment given.

Considerations about items being accidentally omitted or discussed verbally do not hold as strong a weight in legal terms as the principle that what is not documented is seen as not done. This underscores the critical importance of accurate and timely record-keeping in medical practice to ensure that all aspects of patient care are captured and can be relied upon for future medical decisions. Therefore, the presumption made when something is not charted in the health record directly supports the practice's integrity and accountability.