Risk Management Series 1- Documentation in Allied Health

Tip #6: Things to Possibly Avoid in Documentation

There are times you may need to be cautious about what to document. Check to see if your state has rules about documenting information on third parties, including names, and if there are rules indicating a third party may have a claim against you if you release records with his/her name, even if the person is not your patient. In addition, here are a few things to potentially avoid (keeping in mind this depends upon the patient and the circumstance):

  • Abbreviations that differ from the acceptable, standard abbreviations
  • Blank spaces/pages when documenting in written form
  • An informal or curbside consult. Unlike formal consultations, informal consultations are not typically documented. This is not across the board and may vary depending on your facility.
  • Avoid documenting words such as “error,” “mistake,” “accident”
  • Issues that are not vital to treatment
  • Subjective documentation
  • Finger pointing or placing blame on another provider

Note, these principles may vary depending upon the patient, the situation, and the state in which you practice. 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.