Documentation – The Top 5 Ways to Avoid Malpractice Claims

Follow these 5 documentation tips to avoid future malpractice allegations:

  1. Always maintain thorough and detailed records of care, patient communication, and communication with additional providers.
  2. Create a standardized approach to documentation, and maintain the same record standards for every patient.
  3. Include narrative descriptions to patient records.
  4. Document a detailed account of informed consent and informed refusal discussions.
  5. Maintain healthy working relationships with other providers.