Page 3 - Risk Reduction Series - Documentation Essentials (Part Two)

Table of Contents

PART TWO 5

Documenting Communications with Patients ...........................5

Informed Consent ......................................................................................6

Discharge Instructions and Educational Materials ............12

What Should Not be Documented or Maintained in the

Medical Record .........................................................................................13

Documentation: Pitfalls in Electronic Health Records .........13

Tips to Avoid EHR Pitfalls ..................................................................22

Documentation via Scribe ................................................................. 25

Thorough Documentation ................................................................. 25

Documenting after an Adverse Outcome ..................................30

Avoid Using Disclaimers for Dictation, Voice Recognition
Software, or EHRs ...................................................................................31

Conclusion .................................................................................................34