Cheat Sheet | 合法醫療器材資訊網

2018年8月28日—And,inthemedicalworld,ifyoudidn'twriteitdown,itdidn'thappen.Documentingyourfindingsonaphysicalexamaswellasthereasoning ...

Documentation serves two very important purposes. First, it keeps you out of jail. Okay, okay, incarceration might not be totally realistic, but there are plenty of scenarios in which your actions as a healthcare provider might be called into question. And, in the medical world, if you didn’t write it down, it didn’t happen. Documenting your findings on a physical exam as well as the reasoning for your plan of care serves as a defense in the event another provider, patient etc. doesn’t agree with your actions.

Second, documentation helps with continuity of care. How annoying is it when you’re expected to pick up where another provider left off only to find they left little more than two lines of handwritten chicken-scratch scrawled across the chart as to the patient’s situation? Documenting your findings and plan for the patient allows other providers to continue caring for the individual in your absence. Or, it allows for others to provide care in conjunction with yours wit...