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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. Introduction 4 Why Document? 5 Purpose of the guide 5 Documentation s Impact on Medical-Legal Claims 5II. Purposes of Documentation 6 III. The 6 Essential Elements of Good Documentation 81.

This guide represents an update from the original April 2012 guide and includes . ... healthcare organization and/or healthcare providers breached the standard of care. This is ... reference that where two sets of signatures are present this indicates the assessment or

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