Question

Discuss the correct way of charting in a patient’s record. Analyze the impact of poor documentation in patient care? Give one or two examples. Explain possible legal concerns for poor documentation.

Answer 1

1)Correct way of charting in a patient's record:

•Date, time and signal each entry.

•Although simple, its significance can't be overstated. The timing of activities and evaluations is frequently crucial in piecing collectively facts about deteriorating patients.

•Write your title and role as a heading and the names and roles of all others current at the encounter.

•Make entries right away or as soon as viable after care is given.

•Prompt documentation reduces the threat of you forgetting key details.

•It ensures all other team contributors are aware of any adjustments to a patient’s condition or management plan.

•In reality, this isn’t constantly possible. If you are returning to the patient’s notes later, file truly in the heading that it was written in retrospect, with the modern date and time.

•Be legible.

•There’s no factor documenting properly if no one can decipher it.

•Be thorough, accurate, and objective.

•Maintain a expert tone.

•Sarcasm, tried joking or a casual tone may additionally mirror badly on you.

•Only use permitted abbreviations.

•It will be nice to use no abbreviations at all to deflect/avert confusion.

•If an addendum is made, this must additionally be verbally communicated to other groups and nursing staff.

•Sign off any addenda with time and your information.

•If a mistake is made, right it with a single strikethrough.

•Follow that by means of absolutely signing and relationship the correction.

2) Impact of poor documentation in patients;

•motive you to lose your license.
•contribute to inaccurate exceptional and care information.
•cause misplaced revenue/reimbursement.
•result in poor patient care by other healthcare group members.
•result in inappropriate billing main to fees of fraud.
•interfere with patient-related studies.
•compromise safe affected person care.
•decrease reimbursement/gross revenue.
•contains gaps reflecting bad medical care.
•care will no longer be given completely, it will be incomplete.
•Safe affected person care is compromised due to a nurse's incomplete/inaccurate medical chart.

3)Possible legal concerns for poor documentation;

•Poor documentation diminishes credibility and the capacity to supportquality care was once provided to the patient.

•Poor/inaccuratedocumentation can facilitate litigation against healthcare vendors andthe groups that rent them.

•Insufficient/erroneous documentation conveys inaccurate records among theinterdisciplinary care crew and reasons the healthcare enterprise tobe responsible for mistakes associated to care.

•Lastly, practitioners can be heldliable and negligent for documentation blunders which may want to end result in lossof license, fines or incarceration.