Documentation—The Little Things That Make a Big Difference

07/11/24 • 30 min

Within Normal Limits: Navigating Medical Risks

In this episode, our guest is Heather Westermeyer, a Patient Safety and Risk Manager with COPIC, and the topic is documentation. Heather highlights the role documentation plays in continuity of care—from ensuring an accurate medical history to supporting communication among providers. She also talks about how documentation serves a key purpose in legal protection/defense in medical liability issues and the importance of articulating your thought process. In addition, the discussion touches on best practices, standardized templates and protocols, and the dangers of copying and pasting.

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Disclaimer: Information provided in this podcast should not be relied upon for personal, medical, legal, or financial decisions and you should consult an appropriate professional for specific advice that pertains to your situation. Health care providers should exercise their professional judgment in connection with the provision of healthcare services. The information contained in this podcast is not intended to be, nor is it, a substitute for medical diagnosis, treatment, advice, or judgment relative to a patient’s specific condition.

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Previous Episode

Caring for Geriatric Patients

LaDonna Kelley, a nurse risk manager with COPIC, is the guest for this episode, which looks at patient safety and risk management for geriatric patients. LaDonna tells a personal story about the challenges with caring for this patient population and how certain situational factors impact their care experience. She mentions issues such as hearing limitations, technology, and mobility and being aware of these during interactions. The conversation also examines communication challenges and the importance of clear communication with geriatric patients.

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Next Episode

Managing Risks in the Perioperative Setting

This episode features Renee Blattman, a nurse and risk manager with Copic, who has 20 years of experience in the perioperative environment. The discussion focuses on the challenges and risks in this environment—a high-paced, high-volume, and fast-turnover setting, where there is a lot of pressure to keep the patients moving and the OR schedule tight. Renee talks about the growth and trends in ambulatory surgery centers along with the increased risks of discharge and follow-up care, as patients may need more education and support at home. In addition, she highlights how a culture of safety is essential and how this includes being proactive, collaborative, and mindful as a team.

Feedback or episode ideas email the show at [email protected]