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Documentation & Record Keeping

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. The record can be the facilities tool in defending against charges of errors and misconduct. In addition to background material, treatment plan, record of treatment intervention, progress notes, critical incident reports and routine information, the record should contain documentation of all unusual events.
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