NFO Business of Medicine Web Series: Documentation Essentials for Healthcare Professionals

Documentation in patient health records is used in a variety of ways. It memorializes patient care, facilitates communication among caregivers, forms the basis for coding and billing, provides data pertinent to quality improvement, and may provide information that is critical to the defense of legal action. Unfortunately, documentation issues continue to be a contributing factor in adverse events and malpractice claims. This program addresses common documentation issues and provides realistic strategies to enhance patient safety efforts through documentation. Objectives: Describe the function and benefit of documentation. Identify lessons learned from the defense of claims. Discuss best practices to avoid documentation issues. Establish goals to strengthen documentation.