Records are a durable account of what has happened. Courts may place more trust in records than in eyewitnesses. This may be true because documentation is an immediate response, and eyewitness accounts may be told long after the event is fresh in the observer’s memory. Documentation can be the facility’s tool in defending against charges of errors and misconduct. In addition to background material, treatment plan, record of treatment interventions, progress notes, critical incident reports and routine information, the record should contain documentation of all unusual events.
All documentation should be a clear and accurate accounting of the situation. Do not make the assumption that you will remember the incident exactly as it occurred. Record the incident as soon as possible following the occurrence. When documenting the incident, deal only with the facts and what actually happened; do not provide opinions or personal feelings in your documentation. Be specific, include what staff members had been present, date, time, witnesses other than staff, include conversations with any physicians, family members, other responsible parties and other medical professionals. Always keep in mind that these documents could be used in defending a court case or reviewed by the licensing department and others outside the company.
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