The electronic health record is a legal document and serves as a source of communication among healthcare team members, as well as between the team and the patient. Notably, poor documentation is often identified as a contributing factor to breakdowns in communication, which contribute to patient harm events. Additionally, several studies have found that the use of stigmatizing language in healthcare documentation perpetuates bias and negatively influences medical decision making. This activity explores these issues and reviews best practices to promote the accuracy and integrity of the electronic health record.
