Disclosure Documentation

Disclosure of Harm

Disclosure of harm refers to a required process involving open discussions between a patient and healthcare providers about events leading to patient harm, the harm itself, and plans for future care. The associated patient and/or family conversations are both immediate and ongoing.

Documentation of disclosure should be completed by the person who leads the disclosure conversation (e.g., nurses, physicians, allied health, managers, leaders, or other clinicians). Other disclosure leads without the necessary documentation access should ensure that an enabled member of the disclosure team is assigned to document discussion(s).

Disclosure documentation can be inserted  into a progress note using a SmartLink (".DISCLOSUREHARM"). A disclosure document can be quickly generated from any Letter Forms link under the category of "Chart Access".

Reporting Adverse Events

It is important to report clinical adverse events using the “Reporting & Learning System for Patient Safety (RLS).” This is easily found by doing a chart (global) search for “RLS.”

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