One Dozen Things

Document, Document, Document!

Overview

The importance of keeping good medical records cannot be overemphasized. Records that are clear, organized, complete, legible, and timely facilitate continuity of care among members of the health care team, minimize the risk of medical errors, offer protection from litigation, support hospital accreditation, and maximize reimbursement. When medical records are handwritten, they must be legible and clear, and only approved abbreviations should be used. You will be expected to become skilled at using electronic medical record systems. If something is done but not documented, in many ways it may just as well have never happened. If complications or bad outcomes occur, immediate and thorough documentation decreases the risk of litigation and other adverse consequences. Even mundane details such as recording the date and time of a progress note may prove legally important; therefore, thorough documentation is of great importance.

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