Quick
Tips For Better Documentation by Susan Keane Baker
Don't sign or countersign documented
records without reading them, or at least
having an "editor" read them
first.
Note the prescriptions the patient is
taking that are prescribed by other clinicians.
Resist the temptation to make egotistical
remarks. Don't take credit for favorable
outcomes unless you walso want to take
blame for poor outcomes.
Document care provided to other clinicians'
patients. Consider keeping a log of telephone
calls that can be filed by date. If you
are called upon to remember the advice
you gave while covering for another clinician's
patient, you will be able to retrieve
your written documentation quickly.
Document clinician review and patient
notification of test results. Notifying
patients of normal as well as abnormal
test results is a risk management safety
net for you as well as your patient.
Don't make entries that make the patient
sound sicker than he or she is. You may
want to do this in order to justify a
diagnostic test, an extra day in the hospital
or admission to an extended care facility.
Care given by subsequent health care professionals
may not be in the patient's best interst
as a result of the inaccurate entry.
Date and time your entries. Some professionals
are conscientious about writing the month
and day, but leave off the year.
You Are Welcome To Reprint This Article Please include the following text on your reprint:
Copied with permission of the author,
Susan Keane Baker.
Source: www.susanbaker.com.
If You Are Going To Publish This Article at Your Website Please use the following html code for the reference to our website:
Copied with permission of the author: Susan K. Baker - <a href="http://www.susanbaker.com">Speaker on Patient Satisfaction and Handling Patient Complaints</a>
Printer-Friendly Version