Journal of Healthcare Risk Management: David Badie on the Importance of Healthcare Documentation

Good documentation is the foundation for successful medical malpractice defense, but there are many ways that documentation can fall short. David Badie, New Jersey-based partner at Hall Booth Smith, discussed with the Journal of Healthcare Risk Management the importance of healthcare documentation and that clinicians should be self-motivated to document well.

I always tell providers that their documentation is the one opportunity they have to tell their story, he said. It’s the one chance they have to share the details of their encounters with patients when the details are still fresh in their minds.

Badie encourages clinicians to tell the whole story, making sure the note is complete and accurate. He also advises clinicians to recheck their notes before signing off on them

Do it right away, he said. Often, providers are extremely busy and leave documentation to the end of a shift. Certainly, patient care takes precedence over paperwork, but concurrent documentation is the best way to protect yourself.

As part of his education to providers, Badie often focuses on documenting conversations between providers.

One of the most common mistakes I see is a failure to document communications with other providers, he said. If you speak with another provider about a patient and that patient’s care and treatment, document that conversation.

Subscribers can read the full article on the Journal of Risk Management site.