Legal Aspects of Documentation

Question 1

Purpose of Medical Record

Answer 1

Method of communication (between health care providers, between HCP and patient, between current and future HCP; method of establishing appropriate care/legal document in use of defense

Question 2

Risks and Benefits of EMR

Answer 2

Societal implications, advantages of the systems (record integrity, document management/patient flow, quality of care), good for litigation, once it’s in the system it’s always there

Better quality images, less legibility, eliminate verbal orders, consistency

Question 3

Do’s and Don’ts (the Highlights)

Answer 3

• Chart on correct chart
• If its important to do, its important to chart
• Make sure you follow up and follow through
• Write legibly
• Don’t use the chart as a battleground
• Don’t need to chart recommendations
• Don’t try to save yourself during documentation
• Don’t document what someone else done
• Document telephone/oral conversation with family members as soon as possible - remember quotes are helpful