You are asked to testify in a court case involving a mammographic biopsy with which you were involved as a mammographer.During testimony,a question is raised regarding whether the biopsy was done successfully.You remember clearly that it was and state that.In the patient's health record,there is no written documentation of the biopsy being done.As far as the court is concerned,

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A longstanding basic principle of health record documentation is the adage "not documented,not done." This tenet applies to all health care practitioners who make entries in patient health records.If records are submitted in court in any type of legal case,then the statement holds true.In the absence of the requisite documentation in the health record of what was done to the patient,the assumption is that the event did not take place.

You Are Asked to Testify in a Court Case Involving