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Appropriate Documentation

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eMediNexus    05 January 2023

If a healthcare professional fails to document something that happened during the course of treatment, it is difficult to prove later that it occurred. Accurate charts can help understand what happened to the patient. Appropriate documentation helps the treating doctor in answering the questions raised about duty of care when asked for a statement months or years after the occurrence of an event. Appropriate documentation is necessary from a legal perspective. The purpose of documentation is to accurately record the care given to patients, and the response to care. 

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