Risk Management Guide: Documentation

The medical record provides a detailed history, recorded in real-time, of the patient or condition, care decisions, treatment/care provided, and responses to care. Additionally, medical record documentation provides continuity of care for team members. Quality documentation can help reduce and mitigate patient injuries, while documentation gaps may create opportunities for adverse events and make it challenging to defend good care. Documentation risks Documentation deficiencies can have significant consequences. Adverse events may be caused by omissions, inconsistent, inaccurate, and untimely documentation. These gaps can hinder clinicians and other team members from providing timely, appropriate care. Medical records are the primary…