Understanding the Importance of Documentation

Documentation and verbal communication is an essential part of any heath care professional’s daily routine. Any and all discussion and care provided to a patient, caregiver or family member has to be recorded accurately and without prejudice or judgement. Just the facts.

Sounds simple, but it can become very complex and time consuming rapidly. If it’s not done at the time, a lot can be lost or omitted. A recent article about a small study done with paramedics using body cameras to verify and improve their documentation actually did support the use of these cameras. They were expected to document as usual at first and then allowed to view the videos and edit their documentation based on the viewing.

The question that came up about using this process widely is one of privacy. It would have to pass the HIPAA test before it could be approved, and patients would have to have the right to refuse to have their situation recorded.

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