Documentation Area |
Common Misconception |
Attending Physician Expectation |
|---|---|---|
Medical Decision Making (MDM) |
Listing diagnoses is sufficient | Clear articulation of why decisions were made |
Level of Detail |
More documentation = safer | Relevant documentation that supports risk and complexity |
Use of Templates |
Templates ensure compliance | Templates must be customized to reflect clinical judgment |
Assessment vs. Plan |
Restating data demonstrates work | Synthesizing data into a clear assessment |
Risk Documentation |
Risk is implied by diagnosis | Risk must be explicitly stated and supported |
Consistency Across Faculty |
Expectations vary by attending | Expectations should be consistent across the program |
Use the checklist below to determine where your organization should be focusing documentation education efforts:
☐ Faculty expectations for documentation are clearly articulated
☐ Residents receive consistent guidance across attendings
☐ Feedback focuses on how to improve documentation—not just what’s missing
☐ Documentation corrections decrease as residents advance
☐ Residents understand the rationale behind documentation feedback
Published: 02/11/2026
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