Documentation on the PRMS Blog

A Guest Blog by Donna Vanderpool, MBA, JD, Vice-President of Risk Management It’s the start of a new year, so I just cannot resist offering one resolution to consider for 2012. Here it is: try to document your patients’ treatment records so that someone else can read the record and understand what happened in your treatment and why. The “someone else” could be another clinici ...

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Try this as a way of assessing the adequacy of your own patient records. Pull an “inactive” record from your files (i.e., someone you haven’t seen in 3 years or more). Look through it. – Do your notes bring to mind the patient? – Do you understand what you were doing with that patient, in terms of general medical history, your diagnosis, your treatment plan at the time, and  t ...

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Categories: PRMS Blog, Documentation