Documentation: Strengthening the Patient Story, Part 1-Correct Records

Course overview

Medical records tell the story of patient care, thus contributing to patient safety. Some of the main attributes of good documentation, characteristics that maximize patients' welfare while also reflecting healthcare professionals' competent care, can be described through the framework of five Cs: Correct, Clear, Contemporaneous, Civil and Complete. Each of the five Cs will be discussed in this five part series where we will further define documentation best practices and uncover strategies to enhance medical record keeping.