Strategies for Improving Documentation: Lessons from Medical-Legal Claims

Service: Risk Management
Subject: Care
Setting: Communication
Type: Risk Resource Guides

This resource is only available in PDF. To download, select the icon from the top right-hand corner of this page.

documentation guide cover

In this guide, you'll find:

  • Introduction
    • Why Document?
    • Purpose of the Guide
    • Documentation’s Impact on Medical-Legal Claims
  • Purposes of Documentation
  • The 6 Essential Elements of Good Documentation
    • What care or service was provided 
    • Who received the care 
    • Who provided the care or service 
    • When the care or service was provided
    • Why the care or service was provided
    • The patient’s response and outcomes to the care or service provided
  • Special Considerations for Good Documentation
    • Incident Reports
    • Informed Consent and Informed Choice
    • Other Factors Pertaining to Informed Consent and Informed Choice
    • Medical Directives
    • Making Corrections and Deletions Properly
    • How to Manage Late Entries
    • Email and Text Communications
    • Charting by Exception (CBE)
    • Checklists and Pre-Printed Templates
    • Records Retention
    • Chart Audits: a Valuable Quality Improvement Tool
  • Electronic Health Records (EHRs)
    • Migrating to EHRs
    • Security Protocols – Integrity of the EHR
    • Documenting in the EHR
    • Editing, Correcting and/or Deleting
    • Copy and Paste
    • Make Sure Your Audit Trail is Secured
    • Destruction of Records
    • Legal Considerations
    • Final Tips on Working With EHRs
    • Conclusion
  • Electronic Health Records Checklist
  • References
  • Documentation Quiz
  • Appendix – Chart Audit Guide

Download a copy of the complete guide by selecting the PDF icon near the breadcrumb above.

Date last reviewed:
This is a resource for quality assurance and risk management purposes only, and is not intended to provide or replace legal or medical advice or reflect standards of care and/or standards of practice of a regulatory body. The information contained in this resource was deemed accurate at the time of publication, however, practices may change without notice.