Medical Documentation Issues

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Documentation Matters Toolkit | CMS

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Documentation

Because providers rely on documentation to communicate important patient information, incomplete and inaccurate documentation can result in unintended and …

Preventing Healthcare's Top Four Documentation …

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

According to several HIM experts, the top four documentation mistakes are: Mixed messages from a physician vis á vis misunderstood dictation or illegible handwriting …

Nursing Documentation: How to Avoid the …

https://www.wolterskluwer.com/en/expert-insights/nursing-documentation-how-to-avoid-the-most-common-medical-documentation-errors

Here are some of the top 9 types of medical documentation errors: Sloppy or illegible handwriting …

5 Best Practices for Medical Documentation - Clinical Advisor

https://www.clinicaladvisor.com/home/topics/practice-management-information-center/5-best-practices-medical-documentation/

Document Your Examination. Failure to document a physical examination is the most …

Poor Documentation: Why It Happens and How to Fix It

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

The health care system is awash in clinical documentation, both paper and electronic (sometimes a hybrid of the two), from physician and nurse notes to transcribed dictation …

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 …

Clinical documentation | How to document …

https://onthewards.org/how-to-document-well/

Medical documentation is a document of service that has huge implications for hospital funding. Each issue that is documented is coded and then translated into …

Common Costly Medical Documentation …

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 …

The Consequences of Poor Medical Documentation

https://lhatrustfunds.com/news/the-consequences-of-poor-medical-documentation

Preventing Poor Documentation This particular claim features two common risk management topics: Patient falls and poor documentation. As the above incident …

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