News & Knowledge General Documentation ARE THERE ANY GUIDELINES FOR UNLICENSED HEALTHCARE PERSONNEL’S DOCUMENTATION IN THE MEDICAL RECORD? Curi’s Best Risk Advice on General Documentation Thorough, clear, accurate, objective documentation facilitates continuity of patient care and can improve patient outcomes. The medical record is a legal document. It is your primary defense tool in the event of a malpractice lawsuit. It is important that all entries into the record follow established guidelines for good documentation practices. Unlicensed healthcare personnel (UHP) may be unfamiliar with these rules; therefore, proper training is required. The following are medical record documentation guidelines for ALL medical staff including UHP: Documentation should be complete, concise, and… Are you a Curi member? The full content of this resource is available only to Curi members. Contact us if you are a member but do not have an account yet, or to learn more about becoming a Curi member. Sign in with Curi - or - Sign in with Constellation Curi’s risk mitigation resources and guidance are offered for educational and informational purposes only. This information is not medical or legal advice, does not replace independent professional judgment, does not constitute an endorsement of any kind, should not be deemed authoritative, and does not establish a standard of care in clinical settings or in courts of law. If you need legal advice, you should consult your independent/corporate counsel. We have found that using risk mitigation efforts can reduce malpractice risk; however, we do not make any guarantees that following these risk recommendations will prevent a complaint, claim, or suit from occurring, or mitigate the outcome(s) associated with any of them. READ NEXT May 31, 2024August 13, 2024Hospitals/Health Systems | Practice Management | Risk Management | Unlicensed Healthcare Personnel (UHP) Risk Management Guide: Unlicensed Healthcare Personnel With the increasing demands of time and resources, the role of unlicensed personnel in the medical office setting is expanding. An unlicensed individual is typically anyone… Read more January 6, 2023February 24, 2023Unlicensed Healthcare Personnel (UHP) Unlicensed Healthcare Personnel Toolkit: Virginia Unlicensed healthcare personnel can perform a variety of functions in the medical office setting. It is important to be aware of state specific considerations, which are… Read more January 6, 2023October 29, 2023Unlicensed Healthcare Personnel (UHP) Unlicensed Healthcare Personnel Toolkit: Pennsylvania Unlicensed healthcare personnel can perform a variety of functions in a medical office setting. It is important to be aware of state specific considerations, which are… Read more