Doctor-patient/doctor-family communication is essential for patient/family satisfaction/approval with provided medical care
• Including patients in decision-making in health care always prevents malpractice allegations.
• Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. A medical record chronologically documents the care of the patient and is an important element contributing to high quality care.
• An open exchange of information must be encouraged. This is very important to reduce litigation. Details of interactions should be included in the medical record as they both relate to decisions about current care and can potentially help in future care decisions.
• Key components of this documentation include who participated in the meeting, how they are related to the patient, and the patient's competency if he/she participates in the discussion along with decisions that were made.
• Documentation of physician-patient discussions about patient wishes while the patient is still able to express them can help once the patient is no longer mentally competent.
• Along with medical facts such as physical exam and laboratory values, clinician decision-making and the reasons behind the decisions should be incorporated into the medical record.
• The medical record facilitates the ability of the physician and other health care professionals to evaluate and plan the patient’s immediate treatment, and to monitor his /her health care over time.
• Including patients in decision-making in health care always prevents malpractice allegations.
• Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. A medical record chronologically documents the care of the patient and is an important element contributing to high quality care.
• An open exchange of information must be encouraged. This is very important to reduce litigation. Details of interactions should be included in the medical record as they both relate to decisions about current care and can potentially help in future care decisions.
• Key components of this documentation include who participated in the meeting, how they are related to the patient, and the patient's competency if he/she participates in the discussion along with decisions that were made.
• Documentation of physician-patient discussions about patient wishes while the patient is still able to express them can help once the patient is no longer mentally competent.
• Along with medical facts such as physical exam and laboratory values, clinician decision-making and the reasons behind the decisions should be incorporated into the medical record.
• The medical record facilitates the ability of the physician and other health care professionals to evaluate and plan the patient’s immediate treatment, and to monitor his /her health care over time.
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