Tip #1: Why Is It Important to Document?
Documentation is critical, but there are also times when certain observations or occurrences may not be memorialized when documenting in an electronic medical record (EMR) or in written format. Many of you work in systems where EMRs are used; however, some of you may still document in written form. In either scenario, documentation is important to memorialize the care provided to the patient. It serves many purposes including:
- Contributes to improved patient care and minimizing errors (includes your own care and that of other providers who may be providing service to the patient
- Promotes patient safety
- Ensures that compliance with any rules or regulations in your state
- Recognizes professional standards of practice
- Supports billing/reimbursement for services
Documentation is standard in any Allied Healthcare profession. If you fail to document, you may face license revocation, and if you are involved in a board complaint or lawsuit, your attorney may experience difficulty or be unable to defend a case against you. When documenting, always consider who will be reading your record and why. You certainly do not want to always document with the fear that you will face a board complaint or lawsuit. However, document objectively so a third party reading your record will be aware of the symptoms presented and the care provided.
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.
