Records and documentation are a durable account of what has happened in your organization. Courts may place more trust in records than in eyewitnesses that are asked to testify. This may be true because documentation is an immediate response, and eyewitness accounts may be told long after the event is fresh in the observer’s memory. Proper documentation and records can be the organization’s only tool in defending against charges of errors or misconduct. In addition to background material, treatment plan, record of treatment interventions, progress notes, critical incident reports and routine information, the records should contain documentation of all unusual events that may have occurred.
This documentation should be a clear and accurate accounting of the situation. Do not make assumptions in your account of what has happened; simply state the facts as you know. Make sure you include the following information in your write-up:
These records and documentation can always be used to defend your organization in the event of a lawsuit or they can be viewed the licensing authorities in your state to defend any complaints that may have been reported.