Documentation Best Practices?
US based non-MD provider. I order tests under my own name. My visit and result notes are often lengthy and detailed, partly because of the complexity of the information and partly because I never know how much is needed for CYA. I'm slightly dying of burn out and, as with every medical field, the organization is pressuring us to see more patients which means more documentation.
I want to shorten my notes for sanity sake while still doing what I can to protect myself from patient complaint or lawsuit. Is "reviewed the risks, benefits, and limitations" sufficient/better than providing detailed examples of ("but not limited to") risks/benefits/limitations, or vice versa? Do I really need to include "typically" every other word or is a general disclaimer that outliers can occur enough? My professional org has a recommended outline for documentation but they focus more on the topics you need to hit rather than the level of detail needed or is most protective. As I'm writing this I realize it might be more of a legal question but curious if there are any reputable resources out there that speak to this topic.