Articles Tagged With: Documentation
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Documentation Do’s and Don’ts: Know What Really Matters
“Document, document, document!” is the mantra of healthcare risk management. If it was not documented, did it really happen? If it was documented, was it documented properly? Knowing the right and wrong ways to document can make the difference when defending a malpractice claim or conducting a root cause investigation.
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Ethical Concerns Surround Accessibility and Documentation of Advance Care Plans
Advance care planning often is lacking, especially among marginalized groups. Values-based conversations, standardized documentation, and clinician prompts improve planning. Clear workflows and education help ensure patient wishes are honored, reducing conflicts and ethical dilemmas during critical care.
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SWOT Analysis of Artificial Intelligence in Medicine
Artificial intelligence (AI) is rapidly transforming clinical workflows, especially by reducing documentation time and after-hours work, and improving work-life balance, with studies showing substantial drops in burnout within weeks of implementation. As AI systems continue to demonstrate strong medical knowledge and performance, they offer clinicians a powerful way to elevate accuracy, streamline tasks, and improve patient understanding without replacing clinical judgment.
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Inadequate, Missing, or Inaccessible Goals of Care Documentation Is Ethical Concern
Goals-of-care documentation remains inconsistent and incomplete, limiting goal-concordant care. Research reveals disparities across patient groups and delayed documentation near death, emphasizing the role of ethicists in promoting early, equitable, artificial intelligence-assisted, and standardized documentation of patient preferences and end-of-life wishes.
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Documentation Huddles Improve Quality and Safety
CARE Homecare, an in-home care agency serving seniors in Los Angeles and Orange Counties, CA, use documentation huddles to improve quality of care and the usefulness of records in any legal dispute.
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Documentation About Patient Safety, Not Just Litigation
Clinicians should be reminded that proper documentation is not only about providing a legal defense.
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Avoid Spoiling Documentation with Most Common Errors
Documentation is such a crucial part of risk management that there can never be enough emphasis on how to properly document and how to avoid ruining the value of clinical records if they are ever used in legal matters. Constant education for clinicians is the only way to keep documentation clear and effective.
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Ethicists Make Changes to Improve Consult Documentation
When clinical ethicists provide guidance to resolve a healthcare ethics question, they are making recommendations about a patient’s clinical care. A Veterans Health Administration National Center for Ethics in Health Care Improvement Team set out to make ethics documentation easier, while still maintaining high quality standards.
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Avoid Common Errors in Documentation
Documentation is fundamental to both patient safety and risk management, but quality documentation relies on adhering to best practices and avoiding some of the most common mistakes.
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Goals of Care Discussion Took Place — But Was it Documented?
When clinicians discuss patient goals and preferences, the discussion needs to be added to the medical record for other healthcare providers to access the information when necessary. Yet the documentation often is missing or incomplete.