Nursing

Poor documentation: The consequences

Staff Development Weekly: Insight on Evidence-Based Practice in Education, January 31, 2008

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. That's why every organization should ensure accurate and complete clinical documentation (at any cost).

If documentation is inaccurate:

  • Researchers wouldn't be able to conduct patient-related studies
  • Safe patient care is compromised due to a nurse's incomplete/inaccurate clinical chart
  • Reimbursement/gross revenue is decreased
  • Findings of fraud and abuse will lead to federal prosecution

Editor's note: The above excerpt is from the online course "Nursing CE Series: Nursing Documentation - Reduce Your Risk of Liability." For more information on this and other courses, visit www.hcprofessor.com.

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