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.
0 comments on “Poor documentation: The consequences ”
- CMS seeks comment on quality measures
- Q&A: Why do we receive an edit when reporting fluoroscopy?
- What does case-mix index mean to you?
- Welcome to the new and improved APCs Insider!
- Note similarities and differences between HCPCS, CPT® codes
- OB services: Coding inside and outside of the package
- Differentiate between types of wound debridement
- Complications from immobility by body system
- ICD-10 tip: Coding for infectious and parasitic diseases
- Don’t forget the three checks in medication administration
- Washington passes legislation to increase residency positions
- Understand the tracer methodology survey
- Tip of the week: Prior to a fair hearing, allow the physician in question to object to hearing panel members
- New malnutrition criteria could help ensure consistent coding
- Joint Commission updates FAQs
- ICD-10 opponents mount last-ditch roadblocks to implementation
- Clinical documentation tips for ICD-10