Documentation in patient health records and other clinical systems fulfills many purposes. It records and memorializes patient care, facilitates communication among caregivers, forms the basis for coding and billing, provides data pertinent to quality improvement and may provide information that is critical to the defense of a legal action.
Physicians, dentists and other health care organizations should have written policies and procedures to ensure thorough, consistent documentation and to help address liability issues.
Use this checklist to review important risk management considerations related to documentation and to identify potential areas for improvement.
For these and additional risk management resources, contact Professional Insurance Programs at 800-637-4676 or [email protected]
Submitted By: Professional Insurance Programs
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