Accurate and complete documentation of patient interactions is an integral and critical part of the student’s training. The electronic health record and any handwritten documents are legal documents; they afford protection to the student, the patient, the faculty, and the College should any questions arise about treatment of or interaction with a patient. The patient record contains all pertinent information regarding the patient's medical, dental, emotional, and behavioral background that might impact the type/extent of treatment rendered. Without such information, the possibility of providing inappropriate care is increased. It is also the primary source of information for decisions about the patient's status in the program. Releases, reassignments, transfers, or referrals cannot be made or defended without sufficient documentation. Proper records and information management is also important for monitoring treatment sequencing, facilitating departmental interaction in the treatment decision-making process, and providing accurate data to those to whom patient referrals are made.
