News & Knowledge Virginia Handbook: Documentation WHAT ITEMS SHOULD BE PRESENT IN A PATIENT’S MEDICAL RECORD? The need for careful and accurate documentation in the medical record cannot be overstated. In a malpractice lawsuit, the medical record is an essential element of your defense and may impact the outcome. Clear and comprehensive documentation also enables the physician to plan and evaluate treatments and communicate with other providers. Policies and procedures should govern how and when documentation occurs in your office. Good medical record documentation creates a legal document that accurately and completely reflects the care provided to the patient. Regardless of whether the medical record format is electronic or paper, measures must be taken to ensure its credibility. The… 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 to see full post 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 March 25, 2024March 27, 2024Continuing Medical Education (CME) | Health Policy *NEW* HIPAA Privacy Update In this presentation, Becky Lowman discusses how to develop policies and procedures that comply with individual rights under the HIPAA Privacy Rule and how to implement strategies to avoid an enforcement action by the Office of Civil Rights. Additionally, the learners will learn how to mitigate risks associated with non-compliance with the HIPAA Privacy Rule Read more March 4, 2024March 4, 2024Continuing Medical Education (CME) | Health Policy *NEW* Electronic Communications & HIPAA: Frequently Asked Questions In this presentation, Becky Lowman discusses how to keep ePHI secure in electronic transmission and storage and how to develop and apply policies and procedures that ensure secure transmissions of ePHI. This program also aims to improve learner’s competence in knowing how to develop and implement strategies to mitigate the risks associated with electronic communications. Read more September 11, 2020February 24, 2023Electronic Communication & Social Media | Medical Records | Patient Management Florida Handbook: Electronic Communication and Documentation DOES THE PRIVACY RULE PERMIT ME TO COMMUNICATE WITH PATIENTS USING ELECTRONIC (EMAIL)? The HIPAA Privacy Rule allows covered entities to communicate electronically, provided they use… Read more