Page 29 - APP Collaboration - Assessing the Risk (Part Two)

SVMIC Advanced Practice Provider Collaboration: Assessing the Risk

Your documentation must be complete and answer the

following questions:

• What took place?

• What were your thought processes?

• What actions were taken?

• What instructions were given?

• Does the patient understand the treatment plan?

It must also be accurate – the notes should be unique to
that patient and not be cookie cutter. The note should not

include inconsistencies (acute chest pain, denies chest pain)
or inaccuracies (breast exam in dermatology note). Your

documentation must be completed timely. What do we mean
by complete? Your EHR templates guide you regarding what

elements must be present. As you think about what could be
beneficial in defending your care, your documentation should

also include:

• Both positive and negative findings – for example, if

pertinent, it’s important to document “no inflammation”
and not just leave it as charting by exception.

• Your differential diagnosis – what you were thinking; this
will likely require a few sentences of free text.

• Your decision-making process – if there were particular

guidelines which would suggest that you order a particular
diagnostic test or prescribe a certain type of medication,

but you do not think it is indicated, explain your decision.
Acknowledge why you did not follow national guidelines.

Your recommendations for screenings and any patient
refusal of those is critical. Explain that you advised the

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