Inadequate Medical Documentation

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Issues in nursing documentation and record-keeping …

https://pubmed.ncbi.nlm.nih.gov/22241496/

Good quality record keeping is linked with improvements in patient care, while poor standards of documentation are regarded as contributing to poor quality nursing care. The quality of nursing documentation has consistently been found to be failing to …

Preventing Healthcare's Top Four Documentation …

https://library.ahima.org/doc?oid=107687

Having incomplete documentation can have patient safety impacts like those discussed at the beginning of this article, as well as negative reimbursement impacts. CDI …

Poor Quality Medical Records – Reasons and Solutions

https://www.mosmedicalrecordreview.com/blog/poor-quality-medical-records-reasons-and-solutions-to-address-them/

Inadequate documentation of prescriptions and refills: If the medications prescribed are not properly documented in the medical …

Poor Documentation: Why It Happens and How to Fix It

https://www.fortherecordmag.com/archives/0516p12.shtml

For a coder, "poor documentation would be defined as documentation that lacks the sufficient specificity to assign accurate diagnosis and procedure codes," Siegel says. In …

How To Handle Insufficient Medical Documentation in …

https://www.hrlegalist.com/2014/08/how-to-handle-insufficient-medical-documentation-in-support-of-an-employees-ada-accommodation-request/

August 12, 2014 | By Obermayer. Workplace accommodation issues under the Americans with Disabilities Act (ADA) can be tricky to …

Incomplete Medical Records - Consequences and Solutions

https://www.medicaltranscriptionservicecompany.com/blog/incomplete-medical-records-consequences-and-solutions/

Medical records help healthcare providers evaluate the patient’s profile, make accurate diagnosis, analyze treatment results, and plan treatment protocols. Medical …

Break the Cycle of Poor Physician Documentation

https://www.aapc.com/blog/40817-break-the-cycle-of-poor-physician-documentation/

Many physicians focus solely on procedures and procedure documentation. They are shocked when we express a need for accurate and complete diagnosis codes. The physicians only see reimbursement …

Improper Medical Documentation and Reporting Leads …

https://schwanerinjury.com/medical-documentation-error-lawsuit/

If you or a loved one were injured or died as a result of improper medical reports or documentation, it’s important to contact an experienced attorney to help you get the compensation you deserve. A …

Common Costly Medical Documentation Errors - MOS …

https://www.mosmedicalrecordreview.com/blog/common-medical-documentation-errors-that-could-prove-costly/

Documentation that is misplaced: Misplaced patient data is another grave concern related to medical documentation. Procedure notes ending up in the progress note section is one instance. Physicians not …

Inadequate Nurse’s Notes Lead to Lawsuit - Caring for …

https://www.caringfortheages.com/article/S1526-4114(18)30071-4/fulltext

Thus, their documentation should describe the nurses’ critical thinking process: 1) assessment of a resident’s conditions, causative factors, and/or risk factors; 2) analysis of potential outcomes or consequences; 3) …

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