Documentation

Fall 2020 - Back to Basics: Capturing Documentation

When faced with a stack of charts to complete at the end of a busy day or shift, where does your mind go? To a place of happiness or to a place of frustration?

When faced with a stack of charts to complete at the end of a busy day or shift, where does your mind go? To a place of happiness or to a place of frustration? Does it go to a place of necessity or to a place of burden? More importantly, when your charts are complete, do you deem them to be defensible? Or, do you say to yourself, “I will explain it later if I have to.” 

Dr. Cory Vaudt and senior risk manager Veronica Brattstrom explain that even if you believe your records are defensible, they need to be complete, accurate and paint a clear picture of the patient encounter. Your note is not just a story about your patient; it also helps with continuity of care, aids in patient safety and can provide a legal safety net.

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