If you are a health care provider, one of the most important things you do is document. You document a patient’s history, complaints, findings on exam, and diagnoses. You keep a record of a patient’s current medications and allergies. You record the time spent with a patient and the directions or instructions given to the patient. Good documentation is in the patient’s best interest; it facilitates thorough and accurate health care and protects the clients from other risks. Continue reading “Health Care Risk Management: The Importance of Documentation”