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Health Care Risk Management: The Importance of Documentation

If you are a health care provider, one of the most important things you do is document. You document a patient’s history, complaints, findings on exam, and diagnoses. You keep a record of a patient’s current medications and allergies. You record the time spent with a patient and the directions or instructions given to the patient. Good documentation is in the patient’s best interest; it facilitates thorough and accurate health care and protects the clients from other risks.

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