PHIL 2130 Chapter Notes - Chapter 1.2: Canada Health Infoway, Electronic Health Record
6 May 2020
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The patient"s record is a legal document. Documentation is based on the need for hcps to be accountable for actions. Factors that may decrease liability: complete documentation, consistent with agreed-upon standard of care. Factors that may increase liability: incomplete documentation, care falls below standards. Do not use an argumentative tone or judgmental words. Remember other that other healthcare professionals and patients may have access to the notes. To increase interoperability and contribute to patient safety use: standard abbreviations and generic names, standardized clinical terms. Never alter or delete a prior note! Lack of time: not part of routine activities so it takes extra time, solution: documenting should become part of the daily workflow. Lack of reimbursement: solution: pharmacists should take advantage of the opportunity to demonstrate contributions to patient care by documenting the services provided. Lack of training: some pharmacists have not received formal training on how to document accurately and effectively, solution: competence.
