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Documentation requirements for every patient encounter have increased, leaving less time for the actual practice of medicine. While documentation is a burden to physicians and nurses, it does have unlimited value. Documentation allows for appropriate billing for the time and efforts of the physician, nurse, and other medical specialists. Thorough documentation allows for maximum reimbursement without fear of subsequent legal retribution from various government programs. Furthermore, the medical record is an essential historical document of the patient’s previous medical encounters. Documentation of the patient encounter and treatment will provide a defense to potential subsequent litigation that may ensue. The emergency physician may be unaware that a medical expert is reading a case of a previous patient encounter right now. The documentation of the care provided may preclude the plaintiff’s expert from making assumptions and opinions adverse to the physician. This month’s issue will detail the importance of documentation and outline strategies for reducing risk.

Appropriate documentation: Your first (and best) defense