It's crucial to remember that we are all part of a team. Each role - nurse, dietician, housekeeper, chaplain, and others - plays a vital role in the care of our patients. But one of the most impactful things we can do is make sure our documentation in the medical record is thorough and clear.
Medical records aren't just for billing purposes; they are also communication tools. It's important to include our thoughts, concerns, and plans in the notes so that everyone involved in the patient's care is on the same page. By taking the time to document our observations and actions, we can ensure that our patients receive the best possible care.
Ronald Hirsch is an internal medicine physician and can be reached on Twitter @signaturedoc.
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