Articles - Documentation Issues In Medical Management

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Ensuring Clinical Documentation Integrity and Avoiding …

https://journal.ahima.org/page/ensuring-clinical-documentation-integrity-and-avoiding-common-pitfalls-across-the-continuum-of-care

Ensuring Clinical Documentation Integrity and Avoiding Common Pitfalls Across the Continuum of Care. By Anny Pang Yuen, RHIA, CCS, CCDS, CDIP. In recent years, changing factors in the healthcare landscape, such as the use of electronic health …

Preventing Healthcare's Top Four Documentation …

https://bok.ahima.org/doc?oid=107687

Preventing Healthcare's Top Four Documentation Disasters. By Mary Butler. One of the most famous cases in medical history that led to regulation of the number of hours that …

Issues in nursing documentation and record-keeping …

https://pubmed.ncbi.nlm.nih.gov/22241496/

Good quality record keeping is linked with improvements in patient care, while poor standards of documentation are regarded as contributing to poor quality nursing …

Documentation matters - The Hospitalist

https://www.the-hospitalist.org/hospitalist/article/216687/mixed-topics/documentation-matters

Having clinicians jump through regulatory hoops which do not advance patients’ care, and providers misunderstanding the requirements for level-of-service …

Quality of nursing documentation: Paper-based health …

https://pubmed.ncbi.nlm.nih.gov/28981172/

Background: Nursing documentation is a significant indicator of the quality of patient care delivery. It can be either paper-based or organised within the system known as the …

Medical documentation practice and associated factors …

https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-07809-6

Medical documentation practice The practice by which medical records are written by health workers on patient status, medical care, and medical care responses …

The importance of clinical documentation improvement …

https://journals.sagepub.com/doi/full/10.1177/1833358319854185

The premise of CDI is simple: engage clinicians to improve the clinical documentation in the medical record in “real time” so that it is fit for reporting, analysis …

Inadequate Nurse’s Notes Lead to Lawsuit

https://www.caringfortheages.com/article/S1526-4114(18)30071-4/fulltext

Thus, their documentation should describe the nurses’ critical thinking process: 1) assessment of a resident’s conditions, causative factors, and/or risk factors; …

Poor Documentation: Why It Happens and How to Fix It

https://www.fortherecordmag.com/archives/0516p12.shtml

Failure to properly document can have severe consequences, resulting in the following: • incorrect treatment decisions; • expensive, painful, and/or unnecessary diagnostic …

Clinical documentation | How to document …

https://onthewards.org/how-to-document-well/

There are three fundamental reasons to keep in mind when striving for excellent documentation: 1. It’s a form of communication Good documentation promotes …

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