Page 12 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

• Lacking documentation that patients are notified about the

results of lab or diagnostic studies

• Missing or inadequate informed consent documentation

including the patient’s specific questions and whether

anyone else was present during the discussion

• Late documentation or late completion of office notes

• Missing or inadequate documentation of discharge/follow-
up plans

• Missing or limited documentation of phone calls with
patients

• Missing documentation of after-hours calls

• Missing documentation of phone calls/conversations with
other care providers (consultants, hospital nurses, home

health)

• Lack of a documented rationale when not following the

recommendations of consultants

• Missing, illegible, or “stamped” signatures

• Sparse or missing notes on a patient’s response to

treatment

• Missing documentation on when the patient should return

or other follow-up plans

• Missing documentation of a patient’s non-adherence to the

treatment plan and efforts to improve adherence

• Missing information about patient complaints or

grievances (It may be desirable to include a direct quote of
any comments)

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