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Strategies for Improving Documentation - HIROC

Strategies for Improving DocumentationLessons from Medical-Legal ClaimsA guide for Healthcare Providers and Administrators2 August 2017 Healthcare Insurance Reciprocal of Office4711 Yonge St, Suite 1600 Toronto, Ontario M2N 6K8 Tel: Free: Region1200 Rothesay St. Winnipeg, Manitoba R2G 1T7 Tel: 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. 3 Strategies for Improving Documentation : Lessons from Medical-Legal ClaimsI.

This guide represents an update from the original April 2012 guide and includes . ... should be documented according to organizational policy and professional practice standards. • Avoid ambiguity, judgmental adjectives, ... the involved healthcare team had failed to document assessment and monitoring of the

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