Page 31 - Risk Reduction Series - Documentation Essentials (Part Two)
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SVMIC Risk Reduction Series: Documentation Essentials
• Never alter any prior documentation or insert backdated
information.
• Never use the record to speculate about the causation of
the adverse outcome or express dissatisfaction about other
caregivers, equipment, or administrative processes.
• Never put a copy of an “Incident Report” or include
documentation of corrective actions taken (i.e. an
employee disciplinary action document) in the medical
record.
• Record only the care and treatment of the patient given
during the event.
• Contact an SVMIC Claims Attorney. SVMIC encourages
the reporting of any matter that concerns you or your
practice related to a potential malpractice issue.
Avoid Using Disclaimers for Dictation,
Voice Recognition Software, or EHRs
Have you ever opened up a medical record and seen something
out of place? Immediately you realize there’s been an
overlooked mistake in the medical record, and it takes a couple
of reviews to figure out the intended message. Below are some
humorous examples of dictated notes entered into medical
records without thorough review:
• His headache began when you’re a goat (one year ago)
• The medical record had “heart replacement” but the
patient underwent a hip replacement
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