Tip #6: Things to Possibly Avoid in Documentation
There are times you may need to be cautious about what to document. Check to see if your state has rules about documenting information on third parties, including names, and if there are rules indicating a third party may have a claim against you if you release records with his/her name, even if the person is not your patient. In addition, here are a few things to potentially avoid (keeping in mind this depends upon the patient and the circumstance):
- Abbreviations that differ from the acceptable, standard abbreviations
- Blank spaces/pages when documenting in written form
- An informal or curbside consult. Unlike formal consultations, informal consultations are not typically documented. This is not across the board and may vary depending on your facility.
- Avoid documenting words such as “error,” “mistake,” “accident”
- Issues that are not vital to treatment
- Subjective documentation
- Finger pointing or placing blame on another provider
Note, these principles may vary depending upon the patient, the situation, and the state in which you practice. Be sure to check your profession’s ethical guidelines on documentation principles. When you have questions, it is best to consult an attorney for guidance.