Medical Documentation Legal Issues

Overview of Legal and Ethical Issues in Health Care

https://www.msdmanuals.com/home/fundamentals/legal-and-ethical-issues/overview-of-legal-and-ethical-issues-in-health-care

Proper medical charting is critical to protecting against legal risk

https://www.physicianspractice.com/view/proper-medical-charting-is-critical-to-protecting-against-legal-risk

In countless medical malpractice cases, provider negligence can often be proven by poor, incomplete, or completely absent documentation. In contrast, …

Chapter 7. Legal Issues in the Medical Record | Effective …

https://accessphysiotherapy.mhmedical.com/content.aspx?bookid=464§ionid=40254461

The medical record frequently is the most important document available in defending against or preventing legal actions, including but not limited to personal injury suits, …

Medical Record Documentation and Legal Aspects

https://www.rn.org/courses/coursematerial-215.pdf

Documentation is a form of communication that provides information about the healthcare client and confirms that care was provided. Accurate, objective, and complete …

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. …

Nurse documentation contributes to lawsuit dismissal

https://www.nurse.com/blog/nurse-documentation-contributes-to-lawsuit-dismissal/

After several legal filings, only three allegations remained: The nursing supervisor falsely documented his conversations and actions in the medical …

Defending yourself through documentation

https://www.myamericannurse.com/defending-yourself-through-documentation/

The medical record is meant to be patient centered; criticism of others doesn’t belong there. Instead, follow the required procedures to report staff issues …

Clinical documentation | How to document …

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

The medical record is a way to communicate treatment plans to other providers regarding your patient. This ultimately ensures the highest quality of patient care. …

The Consequences of Poor Medical Documentation

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

As we know, documentation plays an important role in the defense of all healthcare liability claims. This case is no different. The nurse did not document the …

MEDICAL DOCUMENTATION - SlideShare

https://www.slideshare.net/doctorrao/medical-documentation

What is Documentation • Anything written or printed • Relied on as a record of proof for authorized persons • Vital part of professional practice 2. 3. Purposes of Documentation • …