Page 28 - APP Collaboration - Assessing the Risk (Part Two)

SVMIC Advanced Practice Provider Collaboration: Assessing the Risk

Ensure you are following a thorough and standard

documentation checklist that includes:

• Medical, family, and social history

• Current problem list

• Current medication list

• Chief complaint

• Physical exam findings

• Differential diagnosis

• Any care provided during the visit (medications, vaccines,

and procedures)

• Treatment plan and patient understanding/agreement to

the plan

• All orders including referrals

• Clinical summary and patient understanding

• Patient education materials provided

• Return to clinic or follow-up instructions

Correct errors in the medical record with an addendum and

never alter or obliterate a medical record. Contact SVMIC for
recommendations if medical records need to be amended.

Documenting for Defensibility

If a lawsuit is filed your documentation may be the most
important piece of evidence in your defense. Remember, the

plaintiff has a story to tell, which may or may not be accurate.
Your care should be documented so it tells a complete and

accurate story.

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