Strategies for Improving Documentation
Strategies for Improving DocumentationLessons from Medical-Legal ClaimsA Guide for Healthcare Providers and Administrators2 August 2017Healthcare Insurance Reciprocal of Office4711 Yonge St, Suite 1600Toronto, Ontario M2N 6K8Tel: Free: Region1200 Rothesay St. Winnipeg, Manitoba R2G 1T7Tel: Free: of Use: This is a resource for quality assurance and risk management purposes and is not intended to provide legal or medical advice. Every effort has been made to ensure that the information is accurate at time of publication. 3Strategies for Improving Documentation : Lessons from Medical-Legal ClaimsI. Introduction 4Why Document? 5Purpose of the Guide 5Documentation s Impact on Medical-Legal Claims 5II. Purposes of Documentation 6III. The 6 Essential Elements of Good Documentation 81.
documentation policy should reference that where two sets of signatures are present this indicates the assessment or procedure took place under instruction, supervision, or direction. The printed name and . Strategies for Improving Documentation: …
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