Better Documentation

More is not necessarily better. In our desire to be medical-legally sound, many physicians now spend more time with the chart than with the patient. Unfortunately, the adage “document, document, document” probably creates as many legal problems as it solves.

This presentation looks at ways of improving documentation rather than just adding documentation. The case studies evaluate the documentation options when faced with unexpectedly bad clinical outcomes, medical errors, differences of opinion with other providers, threats of being sued, lost charts, patient non-compliance, errors in charting, and late entries. It also evaluates some common documentation “myths” and examines the legal consequences of font size, ink color and choice of punctuation.

Physician Comments

Below are what other physicians have said about this module.

• Thank you, Dr. Cotton for dispelling the myths of documentation. – R. Quinn
• I want to thank Dr. Cotton for his way to approach the reality of the medico-legal dilemmas we face daily. –A. Torres
• Great presentation! – M. Follmer
• One of the best features of these modules is that they were helpful in allaying fear of law suits based on documentary, operational, and technical matters. Practicing consistently good medicine requires enough attention in itself. The suggestions put forth in these modules were easy to understand and simple to implement allowing me to focus my attention on taking care of the patients. Thanks – M. Clinton
• This has been the best series presented to us. This should be given to all practitioners in the US and all the medical schools and residencies – P. Battle
• Extremely relevant, excellent content – L. Wolfe
• All the modules I have completed have been clear, concise, pertinent and easy to listen to. They have been helpful reminders, increased awareness of issues and presented some new information. I would not hesitate to recommend this series to other health providers. – G. Slate
• I would enjoy having more lectures from Dr. Cotton. This is such a stressful subject for any physician that even talking about it creates unease. He addresses the issues in a very practical, nonthreatening way. – J. Zimbelman
• Excellent, once again! – D. Ferrante
• Overall these series of lectures are excellent and should be heard by all physicians. – R. Evans
• Well done. – W. McKee
• I really enjoy the precision of the information and the folksy but expert approach Dr. Cotton takes to delivering this presentation. – L. Boyajian-O’Neill
• Great module; insightful,clear about rules that apply to documentation – W. Lawrence
• excellent, simplifies my life – M. Suenram
• I love emphasis on patient, not the chart. Thank you for validating what I knew was right. It seems all we hear is,”document, document….” – J. Welsh