Strategies for Improving Documentation: Lessons from Medical-Legal Claims
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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
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