Documentation—Telling the Story of Patient Care Within Normal Limits: Navigating Medical Risks

This episode features COPIC Patient Safety and Risk Manager, Amanda Heinrichs, who discusses the importance of documentation—from sharing patient information with other medical team members to supporting care decisions. Amanda covers a wide breadth of documentation issues, such as limiting documentation to only facts about the case, moving past finger-pointing in the event of an undesirable outcome, and timely documentation to ensure quality of care. Furthermore, she talks about insights from attorneys, the pros and cons of using scribes, and conducting assessments to evaluate what is going on with patients to support your documentation.