Examples Of Bad Medical Documentation

Nursing Documentation: How to Avoid the …

https://www.wolterskluwer.com/en/expert-insights/nursing-documentation-how-to-avoid-the-most-common-medical-documentation-errors

Here are some of the top 9 types of medical documentation errors: Sloppy or illegible handwriting Failure to …

Preventing Healthcare's Top Four Documentation …

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

According to several HIM experts, the top four documentation mistakes are: Mixed messages from a physician vis á vis misunderstood dictation or illegible handwriting …

Documentation Bad Habits: Shortcuts in Electronic …

https://library.ahima.org/doc?oid=81008

For example, a medical assistant may complete a history and physical on a patient in totality. The supervising physician may subsequently log in to the record, evaluate only …

60+ Funny Charting Bloopers Found on Actual Medical …

https://nurseslabs.com/26-funniest-charting-errors-found-on-actual-patients-medical-charts/

15 Not-So-Obvious Documentation & Charting Tips for …

https://nursemoneytalk.com/blog/charting-tips-for-nurses

Common Costly Medical Documentation …

https://www.mosmedicalrecordreview.com/blog/common-medical-documentation-errors-that-could-prove-costly/

Documentation that is misplaced: Misplaced patient data is another grave concern related to medical documentation. Procedure notes ending up in the progress note section is one …

Nursing Documentation: Good vs. Bad - CloudCME

https://avera.cloud-cme.com/assets/avera/Activity/9587/Skilled%20Nursing%20Good%20vs%20Bad%20Documentation.pdf

Admission – BAD Admit to skilled level of care for nursing and therapy services. 80-year-old female admit to room 302. Diagnosis includes right hip fracture and chronic CHF. …

Did I Write That? - FADONA

https://www.fadona.org/pdf-forms/FADONA_Speaker_PPTs-Slide-by-Slide/113.pdf

THESE EXCERPTS ARE ACTUAL DOCUMENTATION FROM MEDICAL RECORDS 7 EXAMPLE *DATES CHANGED FOR HIPAA PURPOSES 2/1/13:0900 “PATIENT …

Poor Documentation: Why It Happens and How to Fix It

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

For a coder, "poor documentation would be defined as documentation that lacks the sufficient specificity to assign accurate diagnosis and procedure codes," Siegel says. In …

Clinical documentation | How to document …

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

You may include objective observations about how the patient appears from the end of the bed. For example, “Patient appears pale and in discomfort.” In this section, also include …