What legal principle is associated with documentation in healthcare?

The principle associated with documentation in healthcare is that if it was not recorded, it was not done. This legal principle emphasizes the importance of accurate and thorough documentation in patient care. Proper documentation serves as a legal record of the care provided and can be crucial in case of disputes or audits. It ensures accountability and continuity of care, allowing other healthcare professionals to understand what interventions have taken place and the patient's condition over time.

Effective documentation protects both the patient and the healthcare provider, by providing clear evidence of the care delivered, decisions made, and interactions that occurred. In the absence of documented evidence, it can be challenging to prove that a particular action or treatment was indeed performed, potentially leading to legal implications. This principle reinforces the need for personal support workers and other healthcare professionals to be diligent in their record-keeping practices.