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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 patient harm and make it challenging to defend good care. Documentation risks Documentation deficiencies can have significant consequences. Patient harm 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 source of…

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.