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Apr 29, 2020
The Faintest Ink: Documentation to Defend Quality Patient Care
Carol Murray, RHIA, CPHRM, Senior Patient Safety Risk Manager
Complete and timely documentation of the medical record not only enhances patient care, but it also serves to strengthen your credibility if you are called upon to defend that care.

Sep 01, 2023
Documentation and Scope of Practice Issues in Dentistry
We analyze a case resulting in patient injuries and provide strategies that address documentation and staff protocols.

Sep 01, 2023
Process Failures Lead to Patient Harm in Dentistry
We outline important strategies for documenting the clinical justification for any alternative treatment plan, obtaining informed consent, and providing follow-up care.

Sep 01, 2023
Poor Response to Patient Concerns Contributes to Dental Claim
We offer actionable strategies that can help dental professionals enhance communication and documentation skills.

Jul 28, 2022
Defensible Medical and Dental Records
Richard F. Cahill, JD, Vice President and Associate General Counsel, The Doctors Company
Patient records, which serve a critical function in healthcare delivery and routine clinical operations, can provide key evidence in the event of a professional liability action.

Dec 23, 2020
Orthopedics Case Study: The Danger of EHR Templates
Robin L. Wessels, MBA, RN, Assistant Vice President, Department of Patient Safety and Risk Management, The Doctors Company
This example of an orthopedic claim involving accurate medical record documentation illustrates the importance of exercising caution when using EHR templates.

Sep 01, 2023
Management of Treatment Complications in Dentistry
When treatment complications occur, it is often how the situation is handled that determines the outcome for both the patient and the healthcare provider. These strategies can help dental professionals enhance safety and mitigate risk.

Apr 16, 2020
Shoulder Dystocia Documentation: Implementing a Protocol
Pamela Willis, BSN, JD, Patient Safety Risk Manager II
Shoulder dystocia claims have traditionally been among the most problematic to defend.

Professional Education
Risk Management 101 for Healthcare Professionals: Malpractice, Patient Relations, and Documentation
This is an introductory level course about basic risk management for practicing clinicians focusing on malpractice, patient communication, and documentation. Healthcare professionals new to practice and more experienced will learn the legal elements of a malpractice claim that must be proven for a plaintiff to prevail. We share communication strategies to enhance patient understanding, compliance, and satisfaction while reducing the risk of abandonment when ending patient relationships. We address the importance of documentation, share open notes strategies for success, and strategies to demonstrate quality of care and reduce risk. Documentation examples are provided, as are tips for electronic health record (EHR) and telehealth documentation.