Healthcare VANTAGE POINT®
A Healthcare Risk Management Resource | 2026 Issue 1
Comprehensive documentation is central to effective healthcare risk management. First and foremost, a detailed and accurate healthcare information record enhances care by strengthening communication among providers and team members regarding patient/client/resident needs, diagnostic workup, the plan of care, staff observations and interventions, and responses to treatment.
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In this issue…
- Common Documentation Errors and Causal Factors … page 2.
- Case Scenarios and Key Takeaways … page 4.
- Quick Links to CNA Resources … page 5.
In addition, careful documentation has a positive impact on many other organizational processes, including but not limited to the following:
- Quality assurance and performance improvement, by gathering the information needed to evaluate the level, quality and effectiveness of care.
- Regulatory compliance, by serving as the primary tool by which surveyors, leadership, payors and others can assess adherence to legal requirements, accreditation standards and organizational protocols.
- Peer review, by facilitating data collection in such areas as adverse events, provider outcomes, hospital readmissions, drug usage rates, and patient/client/resident complications and mortality.
- Payor reimbursement, by capturing and confirming the care and services provided.
- Legal defensibility, by providing a real-time, comprehensive, objective and precise record of assessment findings, clinical actions taken and unexpected occurrences in the wake of a claim.
Multiple risk factors can affect documentation quality, including insufficient staffing, inadequate training and flawed digital record-keeping systems. This edition of Vantage Point® reviews common documentation errors and presents several case scenarios from across the spectrum of healthcare delivery, focusing on those
aspects of care most vulnerable to documentation deficiencies. In each case, practical strategies are offered to maximize the healthcare information record’s accuracy, clarity, thoroughness and functionality. Also included is a review of the vital role that sound documentation plays in defending against professional liability claims and regulatory actions brought by state licensing boards.
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Editorial Board Members
Kelly J. Taylor, RN, JD, Chair
Jenn Andriany
Nicole Austin, CPHRM
Janna Bennett, CPHRM
Peter S. Bressoud, CPCU, RPLU, ARe
Elisa Brown, FCAS
Lauren Motamedinia, J.D.
Michelle O’Neill, MN, MBA, PhD, CPHRM, CPPS
Karen Schremp-Schinker, MS, BSN, RN, CCM, CPHRM
Publisher
Patricia Harmon, RN, MM, CPHRM
Editor
Hugh Iglarsh, MA
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