Documentation—Telling the Story of Patient Care

This episode features COPIC Patient Safety and Risk Manager, Amanda Heinrichs, who discusses the importance of documentation—from sharing patient information with other medical team members to supporting care decisions. Amanda covers a wide breadth of documentation issues, such as limiting documentation to only facts about the case, moving past finger-pointing in the event of an undesirable outcome, and timely documentation to ensure quality of care. Furthermore, she talks about insights from attorneys, the pros and cons of using scribes, and conducting assessments to evaluate what is going on with patients to support your documentation.

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Disclaimer: Information provided in this podcast should not be relied upon for personal, medical, legal, or financial decisions and you should consult an appropriate professional for specific advice that pertains to your situation. Health care providers should exercise their professional judgment in connection with the provision of healthcare services. The information contained in this podcast is not intended to be, nor is it, a substitute for medical diagnosis, treatment, advice, or judgment relative to a patient’s specific condition.