Nursing

The consequences of an incomplete medical record

Staff Development Weekly: Insight on Evidence-Based Practice in Education, November 18, 2005

An incomplete medical record

  • demonstrates that care was incomplete
  • contains gaps reflecting poor clinical care
  • demonstrates noncompliance with organizational policies
  • is used to support allegations of negligence
  • is used to support allegations of fraud

Clearly, incomplete documentation in patient clinical records can result in legal actions. In addition, it can

  • cause you to lose your license
  • contribute to inaccurate quality and care information
  • cause lost revenue/reimbursement
  • result in poor patient care by other healthcare team members
  • result in inappropriate billing leading to charges of fraud
  • interfere with patient-related studies
  • compromise safe patient care
  • decrease reimbursement/gross revenue

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

Editor's note: The above excerpt is from the online course, "Basic Guidelines for Proper Documentation." For more information on this and other courses in our library, go to www.hcprofessor.com.

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