Often when discussing documentation in a medical record we ask the question, is it our best defense or worst enemy? Good documentation offers valuable insight into the quality of care provided and the patient safety measures taken at the time of care. If the notes are not clear, it can make defense of a medical professional liability claim very difficult to defend.
Understanding and consistently practicing appropriate documentation of patient information, healthcare interventions and the processes followed are a vital part of every healthcare professional’s responsibility. However, critical details often get abbreviated or condensed due to the many hats often worn by a single healthcare provider. Over time, the day-to-day task of data input can become tedious; with mistakes, vagueness, or irregularities leaving potentially big holes in the patient record. It is important for us to understand some of the barriers of good documentation and how to overcome them; including form-fatigue, copy and paste, etc. It’s important to see good versus bad documentation, as well as the benefits and consequences of each in order to understand why it matters.
Join us in March and April for our Documentation Risk Focus Area as we explore best practices to help you assess and improve this critical skill. Webinar sessions will include Basic Documentation Principles, Documentation Principles as they relate to the Electronic Healthcare Record and Pressure Injury Strategies. We will also discuss documentation as it relates to Emergency Preparedness in light of the relevance to current times.
Dates and times with registration links are included here.
Remember, our 2022 Risk Prevention Strategy encompasses not only these education offerings, but our Inspirien Risk Team will also share best practices and resources helpful for taking the next step in the process improvement journey. This is applicable for building a risk prevention strategy for you, personally, as a healthcare professional, as well as for your team and organization.
This risk management program is included as part of the Inspirien and HWCF benefit package and; therefore, limited to those insureds and members. If you would like more information on how you, too, could receive these and other great benefits, please explore our website or contact a member of our team at riskmanagement@inspirien.net.