Documentation—The Little Things That Make a Big Difference

In this episode, our guest is Heather Westermeyer, a Patient Safety and Risk Manager with COPIC, and the topic is documentation. Heather highlights the role documentation plays in continuity of care—from ensuring an accurate medical history to supporting communication among providers. She also talks about how documentation serves a key purpose in legal protection/defense in medical liability issues and the importance of articulating your thought process. In addition, the discussion touches on best practices, standardized templates and protocols, and the dangers of copying and pasting.

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Disclaimer: Information provided in this podcast should not be relied upon for personal, medical, legal, or financial decisions and you should consult an appropriate professional for specific advice that pertains to your situation. Health care providers should exercise their professional judgment in connection with the provision of healthcare services. The information contained in this podcast is not intended to be, nor is it, a substitute for medical diagnosis, treatment, advice, or judgment relative to a patient’s specific condition.