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The consequences of an incomplete medical record

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

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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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