Page 27 - APP Collaboration - Assessing the Risk (Part Two)

SVMIC Advanced Practice Provider Collaboration: Assessing the Risk

Finally, it is important that these educational efforts, along with

the patient’s understanding of the vital role they play in their
therapy, are documented in the medical record.

We have already discussed the clinical or visit summary,

but it is worth repeating. Including clear instructions in such
summary is a good way to help ensure your patient is taking

the correct medication at the correct dosage at the end of the
patient encounter or at hospital discharge and is a great safety

net. By and large most medication errors are preventable,
particularly when they happen as a result of a poorly designed

or implemented system.

Documentation

As stated at the beginning of the course, 75 percent of

documentation errors were related to inadequate or omitted
documentation. So, what do we mean by inadequate

documentation? That can vary somewhat by specialty. For
example, when we look at primary care lawsuits, the most-

frequently identified areas of inadequate documentation were
the failure to document patient or family history, pertinent details

of the physical exam, the rationale for decision-making and the
treatment plan, patient education, phone calls with the patient,

and recommendations for screening.

SVMIC has an entire course addressing documentation, so
we will just cover the basic principles here. Your practice or

organization should have written policies and procedures to
ensure thorough, accurate, and consistent documentation.

Timely, concise, and objective documentation is the goal. Avoid
any subjective, negative, judgmental, or offensive comments

about patients, families, or other care providers.

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