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

SVMIC Risk Reduction Series: Documentation Essentials

• Try also to obtain the patient’s signature on an informed

refusal form (a sample of a general informed refusal form
may be downloaded at vantage.svmic.com). By using a

refusal of treatment form, the patient may better appreciate
the potentially serious consequences of his or her decision.

If the patient refuses to sign the form, the documentation in
the record regarding any discussion(s) with the patient, the

reasons for refusing the care, and his or her refusal to sign
the form will suffice.

• If the patient was referred to the provider as a consult,
the provider must be sure to document the previous

information in a letter to the referring physician.

Discharge Instructions and Educational

Materials

The use of discharge instructions or clinical-visit summaries
and computer-assisted educational materials can save time
and reduce miscommunication about follow-up instructions.

Document any education materials provided to the patient.

Carefully document your discharge instructions, noting the
communication processes employed to establish patient
understanding. This could include a post-encounter visit

summary, techniques such as “read-back” and instructions

given to those accompanying the patient. Include the main
points discussed during the encounter. Include the specific
warning symptoms that should provoke a follow-up contact.

Utilizing a standardized format or template to convey the

key points from the visit or hospitalization can improve
documentation. A three-year study at a community teaching

hospital found that the use of a template while dictating

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