Quick Answer: What Is Poor Documentation?

What is the risk of not documenting procedures?

The absence of well-documented controls leads to gaps in security risk control processes.

This creates a security environment that is difficult to monitor or measure and can lead to non compliance with Health Insurance Portability and Accountability Act (HIPAA) requirements and extensive fines..

How is medical documentation used as medical communication?

It’s a form of communication Good documentation promotes continuity of care through clear communication between all members involved in patient care. 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.

What are possible consequences of poor or incomplete documentation?

Incomplete documentation in patient clinical records can cause your organization legal and settlement fees, cause you to lose your license, contribute to inaccurate statistical databases, cause lost revenue/reimbursement, and result in poor patient care by other healthcare team members.

What are some examples of poor documentation practices in patient records?

Examples of medical documentation errorsSloppy or illegible handwriting.Failure to date, time, and sign a medical entry.Lack of documentation for omitted medications and/or treatments.Incomplete or missing documentation.Adding entries later on.Documenting subjective data.Not questioning incomprehensible orders.More items…•

What is meant by documentation?

Documentation is any communicable material that is used to describe, explain or instruct regarding some attributes of an object, system or procedure, such as its parts, assembly, installation, maintenance and use. Documentation can be provided on paper, online, or on digital or analog media, such as audio tape or CDs.

How do you correct documentation errors?

Handling documentation errorsDon’t obliterate the mistaken entry. … Make the correction in a way that preserves the original entry. … Identify the reason for the correction. … Follow facility policy when adding late information. … Never alter words or numbers after you’ve written them. … Correct mistakes promptly.

How do you prevent documentation errors?

Don’t use vague terms, such as “fair” and “normal.” Be clear, concise, and specific in your documentation. Do correct errors. Draw a straight line through incorrect entries, and write “error” above them. Initial and date the correction.

Why is proper medical documentation important?

Good documentation is important to protect your patients. Good documentation promotes patient safety and quality of care. Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time. At the end of the day, that’s what really matters.

What is improper documentation?

If documentation doesn’t give a clear presentation of a patient’s history, it is termed improper documentation.

What are three examples of poor documentation practices in patient records?

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 (EHR) Incomplete or missing documentation.

What is documentation and why is it important?

Documentation provides a written account of things as they happen, or very soon after. This is especially important in regards to legal matters, audits, or disputes. You see, human memory isn’t perfect, and the more time passes, the more details become confused and hazy.

How can doctors improve documentation?

5 steps for engaging physicians in clinical documentation improvement programsDetermine which physicians will benefit the most. … Make a compelling case to physicians using evidence-based reasoning. … Educate through a documentation training session. … Provide ongoing progress and performance monitoring and support.More items…•