Medical Legal Issues Charting

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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, negligence …

Charting and Documentation | Chronicle of Nursing.

https://www.asrn.org/journal-chronicle-nursing/341-charting-and-documentation.html

Charting should occur when a patient is transferred - before, during, and after - to another unit in the facility, or to and from another facility. It should also occur for …

Medical Record Documentation and Legal Aspects

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

There are many different approaches to charting, but nurses should remember to always follow the nursing process because that’s the basis for documentation, regardless of the …

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, …

25 Legal Dos and Don'ts of Nursing Documentation …

https://www.thehealthlawfirm.com/uploads/25%20Legal%20Tips%20For%20Nursing%20Documentation.pdf

2. Do chart your normal findings. This is especially important where the nurse is monitoring a patient who is critically ill or in labor, where things can change from good to bad on a …

Documentation Bad Habits: Shortcuts in Electronic …

https://library.ahima.org/doc?oid=81008

Electronic documentation habits such as copy and paste save valuable time, but they can ruin the record. As the patient’s health worsened, a hospital stay of days turned to weeks. …

Documentation Matters Toolkit | CMS

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

Accurate documentation supports compliance with federal and state laws and reduces fraud, waste, and abuse. Documentation Matters Fact Sheet for Medical …

Ethical Standards for Clinical Documentation …

https://www.ahima.org/media/r2gmhlop/ethical-standards-for-clinical-documentation-integrity-cdi-professionals-2020.pdf?oid=301868

Clinical documentation integrity professionals shall: 3.1. Participate in the development of query policies that support documentation integrity, and meet regulatory, legal, and …

Copying and Pasting Patient Treatment Notes | Journal …

https://journalofethics.ama-assn.org/article/copying-and-pasting-patient-treatment-notes/2011-06

The medical record of today is not only a clinical record to inform other physicians and health care workers of our finding, thoughts, and plans; it is also used as a legal …

Legal Issues: Patient Charting | MedEsthetics

https://www.medestheticsmag.com/business/legal/article/21147712/legal-issues-patient-charting

Legal Issues: Patient Charting Charting Basics. A properly maintained medical chart should contain the full story of each patient encounter—who the... Coming …

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