Medical Documentation Problems

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 Misuse of copy and paste or copy forward functions in the electronic health record …

Nursing Documentation: How to Avoid the Most Common Medical ...

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

Documentation Matters Toolkit | CMS

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

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 …

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 …

Top Three Clinical Documentation …

https://mcbeeassociates.com/insights/blog/top-three-clinical-documentation-challenges/

Learn the top three clinical documentation challenges and how to address them Executing flawless clinical documentation challenges many providers and is top of …

Poor Documentation: Why It Happens and How to Fix It

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

"Documentation that fails to concisely convey a patient's problem and the logic used to address that problem risks patient safety and obfuscates any effort to estimate the quality …

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 …

Clinical documentation | How to document …

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

There are three fundamental reasons to keep in mind when striving for excellent documentation: 1. It’s a form of communication Good documentation promotes …