Simple tips for Good Documentation Practices | Knowledge Development by Pharma Udyog

Measuring the outcome of a treatment protocol can provide for great case studies when communicated with physicians. What do great case studies and gauging patient satisfaction have in common? They both require Good Documentation Practices (GDP). Most healthcare providers are too busy to take the time and effort to follow up with their patients in a consistent and documented manner.
To make sure GDP are followed, documents should be made:
  1. Accurate: The document must be error free – accurate data
  2. Complete: Required information must be attached to document
  3. Permanent: Cannot be erased
  4. Legible: The document must be understandable
  5. Timely: Required information must be documented at the time the work is performed. NO back dating
  6. Clear: The document must limit the misinterpretation of what was performed or recorded
  7. Traceable: Each aspect of the document must be traceable, such as, who recorded it, where and why.
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