Documenting the Error Disclosure
After disclosing the error, document the conversation in the chart. You should include:
- Date and time of the disclosure
- Descriptions of all persons present
- What was stated
- The patient's/family's expressed understanding, questions, and the answers to those questions
- Plans for follow-up
Avoid:
- Documenting information unrelated to patient care (e.g. "risk management notified")
- Altering any part of the medical record