Tip #5: What Should or Should Not be Documented?
Documentation is critical to reflect care provided. It is essential for current treatment, can be important years later for subsequent treatment, and can be used if a legal issue arises. What should or should not be documented will depend on the patient, the type of care provided, and the specific circumstance of the case. The record may include:
- Patient’s history
- Medication dosages and the prescriber’s name
- Signed informed consent for:
- Date and time of patient encounter/session
- Objective documentation of compliance and progress
- Any boundary issues between you, other providers
- Proper termination when care ends, even when the patient terminates care
- Formal consultations with other providers
- Depending on your type of practice, suicidal or homicidal history or ideation and actions taken
- Any relevant information to support the care provided
- Documentation of reasons if you deviate from standard treatment
It is important that you are aware of any state requirements for documentation. 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.
