Risk Management Series 1- Documentation in Allied Health

Tip #5: What Should or Should Not be Documented?

Documentation is critical to reflect care provided.  It is essential for current treatment, can be important years later for subsequent treatment, and can be used if a legal issue arises.  What should or should not be documented will depend on the patient, the type of care provided, and the specific circumstance of the case.  The record may include:

 

  • Patient’s history
  • Medication dosages and the prescriber’s name
  • Signed informed consent for:
  • Billing
    Treatment
    Communication with other providers, family members, etc.
  • Date and time of patient encounter/session
  • Objective documentation of compliance and progress
  • Any boundary issues between you, other providers
  • Proper termination when care ends, even when the patient terminates care
  • Formal consultations with other providers
  • Depending on your type of practice, suicidal or homicidal history or ideation and actions taken
  • Any relevant information to support the care provided
  • Documentation of reasons if you deviate from standard treatment

It is important that you are aware of any state requirements for documentation.  Be sure to check your profession’s ethical guidelines on documentation principles.  When you have questions, it is best to consult an attorney for guidance.

 

 

Kristen Lambert, JD, MSW, LICSW, CPHRM, FASHRM
Healthcare Practice and Risk Management Innovation Officer
Trust Risk Management Services, Inc.
email: contact@trustrms.com


NOTE: This information is provided as a risk management resource and is not legal advice or an individualized personal consultation.  At the time this resource was prepared, all information was as current and accurate as possible; however, regulations, laws, or prevailing professional practice standards may have changed since the posting or recording of this resource. Accordingly, it is your responsibility to confirm whether regulatory or legal issues that are relevant to you have since been updated and/or to consult with your professional advisors or legal counsel for timely guidance specific to your situation. As with all professional use of material, please explicitly cite The Trust Companies as the source if you reproduce or distribute any portion of these resources.  Reproduction or distribution of this resource without the express written permission of The Trust Companies is strictly prohibited.



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NOTE: This information is provided as a risk management resource and is not legal advice or an individualized personal consultation. At the time this resource was prepared, all information was as current and accurate as possible; however, regulations, laws, or prevailing professional practice standards may have changed since the posting or recording of this resource. Accordingly, it is your responsibility to confirm whether regulatory or legal issues that are relevant to you have since been updated and/or to consult with your professional advisors or legal counsel for timely guidance specific to your situation. As with all professional use of material, please explicitly cite The Trust Companies as the source if you reproduce or distribute any portion of these resources. Reproduction or distribution of this resource without the express written permission of The Trust Companies is strictly prohibited.