More than Words: Why Proper Documentation is a Liability Issue
Lauren Young, LCSW, Kaplan University Human Services Instructor
As a human service professional and Kaplan University Instructor, I am continuously mindful of the importance of students becoming engaged in the process of crafting well-written documentation. Most professionals require documentation to certify events that have occurred or to ensure information discussed during a meeting or session is captured for future use. In our everyday reliance on documentation, human service professionals sometimes use abbreviations or lingo. While this may reduce time spent on documentation writing tasks, the time saved can be a potential liability issue.
Professional documentation may be utilized for legal proceedings such as malpractice lawsuits, client custody proceedings, or even criminal investigations. If there is language not understood by others, it could cause the documentation to be questioned. Other liability concerns would be an unexpected injury or death to a worker. A peer may then be required to utilize the documentation of another professional, and if there are abbreviations or lingo, it may make understanding the content a challenge, or disrupt the workflow of the project or client case. In all of these scenarios clear, concise and well-written documentation is vital, but so too is the assurance anyone could read the documentation and fully understand what is being communicated.
I was always encouraged to document in a manner that could be fully understood by an individual reading it from outside of the human services profession. This rule is an excellent guide to ensure your documentation will meet all potential future needs for any purpose required. Often in our rush to complete our professional writings, we get too comfortable with shortcuts. It is imperative in all career roles that we maintain a professional approach to documentation. This not only benefits our clients, employers, and ourselves, but it also reduces future liability risks we may not anticipate.
Thank you for the response. Your example illustrates the vital importance of what we write (and how) in the field. I appreciate your interest and your sharing of my post to help spread the word.
Lauren, wonderful advice. I have been teaching medical transcription for 20 years and miss communication in a patient’s record can mean life or death! Thanks for the reminder. I will forward your link on to them I know they will enjoy reading your post.
Kathy Bishop, KU Health Sciences Dept.