Expert witness review of medical and behavioral health documentation frequently reveals critical documentation deficiencies that needlessly expose providers to liability. Clinicians often fail to realize who the audience of their notes will be and how those future readers are likely to be oblivious to the context those providers work in and take for granted. Documentation of the exercise of judgment and decision-making at critical points of care saves careers.

Educational Objectives

• Explain the medicolegal relevance of the exercise of judgment and the use of phrases to document the exercise of judgment concerning provision of care
• Review how to concisely document informed consent, risk-benefit analysis, and patient ability (or inability) to self-advocate in the clinical record
• Describe the highest liability risk encounters and the types of questions reviewers often raise regarding the care provided

Level: Intermediate