{"id":4151,"date":"2026-10-26T14:23:19","date_gmt":"2026-10-26T14:23:19","guid":{"rendered":"https:\/\/drsoniafawad.com\/?p=4151"},"modified":"2026-10-26T14:23:19","modified_gmt":"2026-10-26T14:23:19","slug":"qa-to-lessen-legal-risk-do-good-medicine-and-document-what-you-do","status":"publish","type":"post","link":"https:\/\/drsoniafawad.com\/?p=4151","title":{"rendered":"Q&#038;A: To lessen legal risk, \u2018do good medicine and document what you do\u2019"},"content":{"rendered":"<p><br \/>\n<\/p>\n<div data-component=\"ArticleContent\">\n<div class=\"article__below-title\">\n<div class=\" article__posted-date\">\n<p>October 26, 2026<\/p>\n<p>1 min watch<\/p>\n<\/p><\/div>\n<div class=\"mobile-trust-box\">\n<div class=\"row\">\n<div class=\"col-12 col-md-6 offset-md-1 offset-xl-0 col-xl-12\">\n<div class=\"email-alert-button-wrapper d-none\" data-component=\"EmailTopicAlert\" data-module=\"Subspecialty Email Topic Alerts Top\" data-manage-email-link=\"\/footer\/account-information\/my-account\/email-subscriptions-and-alerts#emailAlerts\">\n  <hidden data-setting-item=\"d265901d-6d37-49c7-a8f6-c7bf19a02509\"\/><br \/>\n  <hidden data-crm-source=\"Subspecialty Topic Alert\"\/><\/p>\n<div class=\"email-alert-button d-none\" data-topic-button=\"not-subscribed\">\n<p>&#13;<br \/>\n      <span data-module-track-action=\"Email Alerts TOP_Click_Healio News Article\" data-module-track-label=\"Email Alerts TOP_Healio News Article\">&#13;<br \/>\n        <i class=\"fas fa-plus-circle\"\/>&#13;<br \/>\n        Add topic to email alerts&#13;<br \/>\n      <\/span>&#13;\n    <\/p>\n<div class=\"email-alert-inner collapse u25733f7a188f40019b5c1f0da2088bb3\">\n<div class=\"email-alert-dialogue\">\n<p>&#13;<br \/>\n          Receive an email when new articles are posted on <span data-content=\"topic-title\"\/>&#13;\n        <\/p>\n<div class=\"d-none\" data-sign-up-type=\"unknown\">\n          Please provide your email address to receive an email when new articles are posted on <span data-content=\"topic-title\"\/>.<\/p><\/div>\n<\/p><\/div>\n<p>      <button type=\"button\" class=\"btn btn-primary\" data-loading-text=\"Loading &lt;i class=\" fa=\"\" fa-spinner=\"\" fa-spin=\"\">&#8220;&#13;<br \/>\n              data-action=&#8221;subscribe&#8221;&gt;&#13;<br \/>\n        Subscribe&#13;<br \/>\n      <\/button>\n    <\/div>\n<\/p><\/div>\n<div class=\"d-none\" data-topic-modal=\"failed\">    <strong>We were unable to process your request. Please try again later. If you continue to have this issue please contact <a href=\"https:\/\/www.healio.com\/news\/primary-care\/20261026\/mailto:customerservice@slackinc.com\">customerservice@slackinc.com<\/a>.<\/strong>  <\/p>\n<p><button data-dismiss=\"modal\" class=\"btn btn-primary btn-lg btn-block\">Back to Healio<\/button><\/p>\n<\/div>\n<\/div><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/div>\n<h2>Key takeaways:<\/h2>\n<ul>\n<li>Thorough documentation should reflect clinicians\u2019 clinical reasoning, including diagnoses considered and ruled out.<\/li>\n<li>Clinicians should also understand the difference between decision-making capacity and consent.<\/li>\n<\/ul>\n<p>LAS VEGAS \u2014 Physicians can mitigate their legal risk by documenting their clinical reasoning and staying informed about emerging medical-legal issues, a speaker at OMED said.<\/p>\n<p>Medical legal \u201cis always a great topic for people to learn more\u201d about, <b>John <\/b><b>R. <\/b><b>Casey, DO, MA, FACOEP-D,<\/b> director of medical education at OhioHealth Doctors Hospital, told Healio.<\/p>\n<figure class=\"figure article__og-image\">&#13;\n    <picture>&#13;<source srcset=\"https:\/\/www.healio.comhttps:\/\/www.healio.comhttps:\/\/www.healio.com\/~\/media\/slack-news\/stock-images\/rheumatology\/j\/judge-documents_58702863.webp?w=476\" media=\"(max-width: 768px)\">&#13;<source srcset=\"https:\/\/www.healio.com\/~\/media\/slack-news\/stock-images\/rheumatology\/j\/judge-documents_58702863.webp?w=800\" media=\"(max-width: 992px)\">&#13;<source srcset=\"https:\/\/www.healio.com\/~\/media\/slack-news\/stock-images\/rheumatology\/j\/judge-documents_58702863.webp?w=595\" media=\"(max-width: 1200px)\">&#13;<source srcset=\"https:\/\/www.healio.comhttps:\/\/www.healio.comhttps:\/\/www.healio.com\/~\/media\/slack-news\/stock-images\/rheumatology\/j\/judge-documents_58702863.webp?w=476\" media=\"(min-width: 1200px)\">&#13;<source srcset=\"https:\/\/www.healio.comhttps:\/\/www.healio.comhttps:\/\/www.healio.com\/~\/media\/slack-news\/stock-images\/rheumatology\/j\/judge-documents_58702863.webp?w=476\">&#13;<br \/>\n&#13;<br \/>\n      <img decoding=\"async\" src=\"https:\/\/www.healio.com\/~\/media\/slack-news\/stock-images\/rheumatology\/j\/judge-documents_58702863.jpg?w=800\" alt=\"Judge documents_58702863\" class=\"figure-img img-fluid\" width=\"800\"\/>&#13;<br \/>\n    <\/source><\/source><\/source><\/source><\/source><\/picture>&#13;<figcaption class=\"figure-caption\">&#13;<br \/>\n      Physicians can mitigate their legal risk by documenting their clinical reasoning and staying informed about emerging medical-legal issues, a speaker at OMED said. <em>Image: Adobe Stock<\/em>&#13;<br \/>\n    <\/figcaption>&#13;<br \/>\n  <\/figure>\n<p>\u201cIt\u2019s not meant to be scary. Some people think it\u2019s a bit dry, but I think it\u2019s interesting if you look at it with the same lens that you look at quality review,\u201d Casey said. \u201cIf you think about it from the fact that we all do medicine, we\u2019re always going to interact with the legal system. So, it\u2019s important to know what\u2019s changing in the medical legal world.\u201d<\/p>\n<p>Healio spoke with Casey about strategies that can lessen the risk for legal action, how AI factors into medical-legal issues and more.<\/p>\n<p>      <b>Healio: What are the <\/b><b>emerging and important areas of legal risk that clinicians should be aware of?<\/b>    <\/p>\n<p>      <b>Casey:<\/b> Most physicians are aware of basic legal risk as the legal landscape, much like medicine, is slow to evolve. I think the areas that they need to focus on are good differentials, considering all factors for the patient and documentation that explains their decision-making.<\/p>\n<p>There\u2019s a commonly held misconception that if you miss some kind of unicorn diagnosis out there, that you\u2019re practicing bad medicine. That\u2019s not what the data supports. The data really supports that it\u2019s when something is not that rare of a diagnosis, but you didn\u2019t consider it, or you did but you didn\u2019t document very well. That\u2019s what really gets people into legal trouble.<\/p>\n<p>      <b>Healio:<\/b><b> How <\/b><b>does<\/b><b> emerging AI <\/b><b>factor<\/b><b> into the legal landscape?<\/b>    <\/p>\n<p>      <b>Casey:<\/b> One of the newer areas that people have concerns about \u2014 and it\u2019s an underdeveloped area because, again, the legal system moves very slowly \u2014 are AI scribes and recording, the use of technology for health system alerts and this technology in <a rel=\"noopener noreferrer\" href=\"https:\/\/www.healio.com\/news\/rheumatology\/20261013\/the-medical-records-evolution-across-generations-whats-next\" id=\"rId9\" target=\"_blank\">electronic medical records<\/a>.<\/p>\n<p>The thing we need to think about in medicine is AI is designed to be a tool to help patients, and they do that by helping the physician do a better job. When you use the AI that\u2019s available to you for the right thing, making sure that the physician is ultimately <a rel=\"noopener noreferrer\" href=\"https:\/\/www.healio.com\/news\/gastroenterology\/20260407\/blended-intelligence-combining-human-wisdom-ai-poised-to-transform-clinical-care\" id=\"rId10\" target=\"_blank\">the person with oversight<\/a>, that really is the safest way to protect yourself. You can get a lot more done a lot safer with having AI rather than without.\u00a0<\/p>\n<p class=\"article__video-player\">&#13;<br \/>\n&#13;<br \/>\n&#13;<br \/>\n    <span class=\"\">&#13;<br \/>\n      <video-js class=\"vjs-fluid\" controls=\"\" data-account=\"1866680400001\" data-application-id=\"\" data-embed=\"default\" data-player=\"1pRc4aob8\" data-playlist-id=\"\" data-video-id=\"6407349040112\" id=\"Vc7d76fa7_c1b0_40ea_94b2_84df3d583335_6407349040112\">&#13;<br \/>\n      <\/video-js>&#13;<br \/>\n      &#13;<br \/>\n    <\/span>&#13;<\/p>\n<figure class=\"av-figure\" data-video-id=\"Vc7d76fa7_c1b0_40ea_94b2_84df3d583335_6407349040112\">&#13;<figcaption class=\"figure-caption\">&#13;<br \/>\n          John R. Casey, DO, MA, FACOEP-D, held a talk at OMED about how physicians can mitigate legal risks.&#13;<br \/>\n        <\/figcaption>&#13;<br \/>\n      <\/figure>\n<p>&#13;<br \/>\n    &#13;<br \/>\n&#13;<br \/>\n&#13;<br \/>\n&#13;<br \/>\n&#13;<br \/>\n&#13;\n<\/p>\n<p>      <b>Healio:<\/b><b> <\/b><b>Are there any medical-legal principles you feel need better education and implementation?<\/b>    <\/p>\n<p>      <b>Casey:<\/b> One of the biggest areas \u2014 and it\u2019s interesting because it goes right to the root of something that we do in medicine all the time \u2014 is the difference between capacity and the ability to consent to things, and I think capacity in general is one of those ideas that seems easy to grasp, but it\u2019s not really the same as competence, and that can really cause problems for people.<\/p>\n<p>You have the right in this country to make a poor decision, as long as you\u2019re informed about the circumstances around that and are choosing to do that. Sometimes we forget that capacity can fluctuate. Someone can have capacity in certain domains, but not in others, and I think that unless you do a lot of work on this or have had recent education on it, some of the thoughts on it since your time in medical school or training have probably changed a bit, and it\u2019s a topic worth revisiting.<\/p>\n<p>      <b>Healio:<\/b><b> Do you have any basic tips for mitigating legal risk?<\/b>    <\/p>\n<p>      <b>Casey:<\/b> The easiest way to mitigate risk is to do good medicine and document what you do. In your medical record, make sure that it\u2019s clear what you thought things were and weren\u2019t, what you considered and what you didn\u2019t. A lot of times we just leave it to assume that everyone would know that\u2019s something we would do, and unless you either ordered a test or documented that you thought about it, it really never makes its way in, and years down the road, you often would have a hard time justifying what you did or didn\u2019t look for, particularly because when you\u2019re playing the game with the final result, it\u2019s a lot easier to question rulings on the play.<\/p>\n<h2>For more information:<\/h2>\n<p>      <b>John Casey, DO, MA, FACOEP-D,<\/b> can be reached at <a rel=\"noopener noreferrer\" href=\"https:\/\/www.healio.com\/news\/primary-care\/20261026\/mailto:primarycare@healio.com\" id=\"rId11\" target=\"_blank\">primarycare@healio.com<\/a>. <\/p>\n<div class=\"article__content--footer\">\n<div class=\"sources-references-disclosures\">\n<h3>Sources\/Disclosures<\/h3>\n<h2> Source: <\/h2>\n<p class=\"citation\">Casey J. Medical legal you need to know. Presented at OMED; Oct. 22-25, 2026; Las Vegas.<\/p>\n<div class=\"disclosures\">\n<p>&#13;<br \/>\n        <strong> Disclosures: <\/strong>&#13;<br \/>\n        Casey reports no relevant financial disclosures.&#13;\n      <\/p>\n<\/p><\/div>\n<\/div>\n<p><!-- Healio AI Widget --><\/p>\n<div class=\"healio-ai-component-inline\" data-no-ads=\"true\" data-module-track-category=\"Healio AI\" data-module-track-action=\"Click\" data-module-track-label=\"Access Healio Ai from component - News_AI Component - In-Content (all devices)\">\n<div class=\"healio-ai-content\">\n    <img decoding=\"async\" src=\"https:\/\/m3.healio.com\/~\/media\/images\/healio-ai\/healio-ai_logo.svg\" alt=\"Healio AI\" class=\"healio-ai-logo\"\/><\/p>\n<p><strong>Ask a clinical question<\/strong> and tap into <strong>Healio AI&#8217;s knowledge<\/strong> base.<\/p>\n<ul>&#13;<\/p>\n<li>PubMed, enrolling\/recruiting trials, guidelines<\/li>\n<p>&#13;<\/p>\n<li>Clinical Guidance, Healio CME, FDA news<\/li>\n<p>&#13;<\/p>\n<li>Healio&#8217;s exclusive daily news coverage of clinical data<\/li>\n<p>&#13;\n    <\/ul>\n<p>    <button class=\"healio-ai-button\" onclick=\"window.location.href=\" https:=\"\">Learn more<\/button>\n  <\/div>\n<\/div>\n<div class=\"email-alert-button-wrapper d-none\" data-component=\"EmailTopicAlert\" data-module=\"Subspecialty Email Topic Alerts Top\" data-manage-email-link=\"\/footer\/account-information\/my-account\/email-subscriptions-and-alerts#emailAlerts\">\n  <hidden data-setting-item=\"d265901d-6d37-49c7-a8f6-c7bf19a02509\"\/><br \/>\n  <hidden data-crm-source=\"Subspecialty Topic Alert\"\/><\/p>\n<div class=\"email-alert-button d-none\" data-topic-button=\"not-subscribed\">\n<p>&#13;<br \/>\n      <span data-module-track-action=\"Email Alerts TOP_Click_Healio News Article\" data-module-track-label=\"Email Alerts TOP_Healio News Article\">&#13;<br \/>\n        <i class=\"fas fa-plus-circle\"\/>&#13;<br \/>\n        Add topic to email alerts&#13;<br \/>\n      <\/span>&#13;\n    <\/p>\n<div class=\"email-alert-inner collapse u25733f7a188f40019b5c1f0da2088bb3\">\n<div class=\"email-alert-dialogue\">\n<p>&#13;<br \/>\n          Receive an email when new articles are posted on <span data-content=\"topic-title\"\/>&#13;\n        <\/p>\n<div class=\"d-none\" data-sign-up-type=\"unknown\">\n          Please provide your email address to receive an email when new articles are posted on <span data-content=\"topic-title\"\/>.<\/p><\/div>\n<\/p><\/div>\n<p>      <button type=\"button\" class=\"btn btn-primary\" data-loading-text=\"Loading &lt;i class=\" fa=\"\" fa-spinner=\"\" fa-spin=\"\">&#8220;&#13;<br \/>\n              data-action=&#8221;subscribe&#8221;&gt;&#13;<br \/>\n        Subscribe&#13;<br \/>\n      <\/button>\n    <\/div>\n<\/p><\/div>\n<div class=\"d-none\" data-topic-modal=\"failed\">    <strong>We were unable to process your request. Please try again later. If you continue to have this issue please contact <a href=\"https:\/\/www.healio.com\/news\/primary-care\/20261026\/mailto:customerservice@slackinc.com\">customerservice@slackinc.com<\/a>.<\/strong>  <\/p>\n<p><button data-dismiss=\"modal\" class=\"btn btn-primary btn-lg btn-block\">Back to Healio<\/button><\/p>\n<\/div>\n<\/div><\/div>\n<\/p><\/div>\n<p><br \/>\n<br \/><a href=\"https:\/\/www.healio.com\/news\/primary-care\/20261026\/qa-to-lessen-legal-risk-do-good-medicine-and-document-what-you-do\">Source link <\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>October 26, 2026 1 min watch &#13; &#13; &#13; Add topic to email alerts&#13; &#13; &#13; Receive an email when new articles are posted on &#13; Please provide your email address to receive an email when new articles are posted on . &#8220;&#13; data-action=&#8221;subscribe&#8221;&gt;&#13; Subscribe&#13; We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com. Back to Healio Key takeaways: Thorough documentation should reflect clinicians\u2019 clinical reasoning, including diagnoses considered and ruled out. Clinicians should also understand the difference between decision-making capacity and consent. LAS VEGAS \u2014 Physicians can mitigate their legal risk by documenting their clinical reasoning and staying informed about emerging medical-legal issues, a speaker at OMED said. Medical legal \u201cis always a great topic for people to learn more\u201d about, John R. Casey, DO, MA, FACOEP-D, director of medical education at OhioHealth Doctors Hospital, told Healio. &#13; &#13;&#13;&#13;&#13;&#13;&#13; &#13; &#13; &#13;&#13; Physicians can mitigate their legal risk by documenting their clinical reasoning and staying informed about emerging medical-legal issues, a speaker at OMED said. Image: Adobe Stock&#13; &#13; \u201cIt\u2019s not meant to be scary. Some people think it\u2019s a bit dry, but I think it\u2019s interesting if you look at it with the same lens that you look at quality review,\u201d Casey said. \u201cIf you think about it from the fact that we all do medicine, we\u2019re always going to interact with the legal system. So, it\u2019s important to know what\u2019s changing in the medical legal world.\u201d Healio spoke with Casey about strategies that can lessen the risk for legal action, how AI factors into medical-legal issues and more. Healio: What are the emerging and important areas of legal risk that clinicians should be aware of? Casey: Most physicians are aware of basic legal risk as the legal landscape, much like medicine, is slow to evolve. I think the areas that they need to focus on are good differentials, considering all factors for the patient and documentation that explains their decision-making. There\u2019s a commonly held misconception that if you miss some kind of unicorn diagnosis out there, that you\u2019re practicing bad medicine. That\u2019s not what the data supports. The data really supports that it\u2019s when something is not that rare of a diagnosis, but you didn\u2019t consider it, or you did but you didn\u2019t document very well. That\u2019s what really gets people into legal trouble. Healio: How does emerging AI factor into the legal landscape? Casey: One of the newer areas that people have concerns about \u2014 and it\u2019s an underdeveloped area because, again, the legal system moves very slowly \u2014 are AI scribes and recording, the use of technology for health system alerts and this technology in electronic medical records. The thing we need to think about in medicine is AI is designed to be a tool to help patients, and they do that by helping the physician do a better job. When you use the AI that\u2019s available to you for the right thing, making sure that the physician is ultimately the person with oversight, that really is the safest way to protect yourself. You can get a lot more done a lot safer with having AI rather than without.\u00a0 &#13; &#13; &#13; &#13; &#13; &#13; &#13; &#13; &#13;&#13; John R. Casey, DO, MA, FACOEP-D, held a talk at OMED about how physicians can mitigate legal risks.&#13; &#13; &#13; &#13; &#13; &#13; &#13; &#13; &#13; Healio: Are there any medical-legal principles you feel need better education and implementation? Casey: One of the biggest areas \u2014 and it\u2019s interesting because it goes right to the root of something that we do in medicine all the time \u2014 is the difference between capacity and the ability to consent to things, and I think capacity in general is one of those ideas that seems easy to grasp, but it\u2019s not really the same as competence, and that can really cause problems for people. You have the right in this country to make a poor decision, as long as you\u2019re informed about the circumstances around that and are choosing to do that. Sometimes we forget that capacity can fluctuate. Someone can have capacity in certain domains, but not in others, and I think that unless you do a lot of work on this or have had recent education on it, some of the thoughts on it since your time in medical school or training have probably changed a bit, and it\u2019s a topic worth revisiting. Healio: Do you have any basic tips for mitigating legal risk? Casey: The easiest way to mitigate risk is to do good medicine and document what you do. In your medical record, make sure that it\u2019s clear what you thought things were and weren\u2019t, what you considered and what you didn\u2019t. A lot of times we just leave it to assume that everyone would know that\u2019s something we would do, and unless you either ordered a test or documented that you thought about it, it really never makes its way in, and years down the road, you often would have a hard time justifying what you did or didn\u2019t look for, particularly because when you\u2019re playing the game with the final result, it\u2019s a lot easier to question rulings on the play. For more information: John Casey, DO, MA, FACOEP-D, can be reached at primarycare@healio.com. Sources\/Disclosures Source: Casey J. Medical legal you need to know. Presented at OMED; Oct. 22-25, 2026; Las Vegas. &#13; Disclosures: &#13; Casey reports no relevant financial disclosures.&#13; Ask a clinical question and tap into Healio AI&#8217;s knowledge base. &#13; PubMed, enrolling\/recruiting trials, guidelines &#13; Clinical Guidance, Healio CME, FDA news &#13; Healio&#8217;s exclusive daily news coverage of clinical data &#13; Learn more &#13; &#13; &#13; Add topic to email alerts&#13; &#13; &#13; Receive an email when new articles are posted on &#13; Please provide your email address to receive an email when new articles are posted on . &#8220;&#13; data-action=&#8221;subscribe&#8221;&gt;&#13; Subscribe&#13; We were unable to process your<\/p>\n","protected":false},"author":1,"featured_media":4152,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-4151","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized"],"_links":{"self":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts\/4151","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=4151"}],"version-history":[{"count":0,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts\/4151\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/media\/4152"}],"wp:attachment":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=4151"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=4151"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=4151"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}