When discussing medical record documentation, we often ask – is it our best defense or our worst enemy? Speaking from someone who has had to defend many clinicians, it’s a vital component of any defense strategy as it provides evidence of the patient safety protocols and the quality of care. Although it may seem like a purely administrative task, it is often a key area of focus in defense of any claim. If done thoroughly and consistently, it is a tool an attorney can rely upon to defend the actions taken.
Appropriate documentation of patient assessments, clinical interventions, and the processes used to support these efforts are essential to capture. However, it can become a cumbersome task in the list of responsibilities of most healthcare professionals. Mistakes, vagueness, or even non-standard language (e.g., Twitter-type responses) can plague a patient record for a lifetime. Electronic documentation further clouds the picture as some tend to pick their favorite “drop-down” or common abbreviations that don’t necessarily paint the full picture of the actions taken. Inspirien would like to take you on a journey to demonstrate why good documentation matters.
Join us in March and April for webinars that will focus on Documentation Risks by exploring several examples (good and bad) and offer some tactical approaches to improving your team’s documentation practices. Webinar sessions will include Basic Documentation Strategies and Documentation Strategies related to the Electronic Healthcare Record. Additionally, we’ve added a webinar on the Root Cause Analysis process to give a better understanding of the documentation elements associated with this process. We will also discuss documentation related to Emergency Preparedness in light of its relevance to current times.
Click to view the dates and times with registration links HERE
Inspirien’s team of Risk Consultants will offer practical resources to help you build actionable initiatives for taking that next step in the process improvement journey. This focus area is just one in the company’s Risk Prevention Series designed to help teams move strategically from a reactive to a proactive focus on risk.
These webinars and others in the company’s Risk Prevention Series are included in the benefits package for Inspirien customers and HWCF members. If you are not a customer and want to know more about Inspirien’s suite of products and services, please get in touch with our Risk Consultants at firstname.lastname@example.org or call 1-800-821-9605 to speak to a member of our Risk team.