After a long day in practice, it may be tempting to simply close the door and turn the lights out, but unless you’ve completed the day’s charts, you still have work to do.
In today's environment of high patient expectations and increased regulatory scrutiny, shortchanging your documentation duties is not a wise move. Your notes are your patient’s story. They not only help with the continuity of care but aid in patient safety. A complete and accurate chart is the only way to detail your patient interaction and support your prognosis.
If you are ever faced with a legal matter regarding your care, a strong clinical record will be your best defense.
For a complete and thorough record, you’ll want the following key points in all of your documentation:
The HPI should contain as much detail as possible about any relevant factors that brought the patient to you. This can be an exhaustive set of details and figuring out what to include may be tricky.
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