CMPA Tips for Residents: Communicate and Document
It’s hard to overstate the importance of communication and documentation in your medical practice.
Documentation informs other healthcare providers of a patient’s condition, special circumstances, and the basis for treatments. It not only promotes quality patient care, it is a legal and ethical obligation for all physicians and acts as evidence in the event your care is ever questioned.
Communication transfers information and knowledge: it helps others to understand. Most importantly, it enables safe patient care. That’s why clear communication with patients and other healthcare providers should always be a top priority.
In this video, lawyers working with the Canadian Medical Protective Association (CMPA) describe real medical-legal issues associated with poor documentation and communication. They also share tips to help you incorporate better documentation and communication into your practice.
Questions about documentation or communication? The CMPA can help
All CMPA members have access to a wide range of services, education and resources (like the Good Practices Guide) designed to help you improve the safety of your practice, and to empower better healthcare.
We are here to:
- Provide general medical-legal advice and answer questions about documentation and communication
- Share risk reduction strategies and risk management tools
- Assist with
- regulatory authority (College) complaints, investigations, and disciplinary hearings
- civil legal issues
- hospital matters
- privacy legislation breaches and privacy complaints
- human rights complaints
Each medical-legal situation is unique and often complex. Members who have medical-legal questions or need advice or assistance should contact the CMPA as soon as their questions arise.
CMPA’s professional, personalized, and confidential advice is only a click or a call away: www.cmpa-acpm.ca, 1-800-267-6522.