Tip Tuesday #0913
Every week, we share what we call, "Tip Tuesday." These are bits of best practices to help awesome clinicians even better in documenting. We came about calling them tips because they are not anything new but simple reminders of the simple things that tend to be overlooked. We hope you find our tips refreshing.
Consistency in your documentation provides for a more solid assessment of the patient and better care. Check that your selections in your visit note form's assessment checklist matches your narrative. For example, under musculoskeletal assessment, checking on weakness, then later documenting in the narrative that the patient does not have weakness.