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Documenting Interventions/Resident Response to Care

Comagine Health

Documentation in the medical record is essential. It provides a chronological record of the residents’ experiences while in your care, is used to create and manage treatment and care plans, and serves as a legal record that may be used in risk management and in defense for litigation. This document summarizes key concepts and ideas shared by LTPAC leaders to help you explore this topic with your team and identify performance improvement opportunities.