Inappropriate Medical Documentation

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Words Matter: Stigmatizing Language in Medical Records May …

https://www.hopkinsmedicine.org/news/newsroom/news-releases/words-matter-stigmatizing-language-in-medical-records-may-affect-the-care-a-patient-receives

A Johns Hopkins study found that physicians who use stigmatizing language in their patients’ medical records may affect the care those patients get for years to come. When …

Physician Use of Stigmatizing Language in Patient Medical …

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2781937

Physician Use of Stigmatizing Language in Patient Medical Records | Electronic Health Records | JAMA Network Open | JAMA Network This qualitative study examines both …

Inappropriate Medical Abbreviations - StatPearls - NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK519006/

All healthcare institutions have now started to formulate guidelines restricting the use of medical abbreviations. While few studies that have quantified the extent of medical …

The do’s and don'ts of calling out a patient's bad behavior

https://www.ama-assn.org/delivering-care/ethics/do-s-and-donts-calling-out-patients-bad-behavior

Guidance from the AMA Code of Medical Ethics addresses the question of unacceptable from either side in Opinion 1.2.2, “Disruptive Behavior by Patients.” “Disrespectful or …

Nursing Documentation: How to Avoid the Most Common Medical ...

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 date, time, and sign a medical entry Lack of documentation for …

Charting Disruptive Patient Behaviors: Are You Objective?

https://allnurses.com/charting-disruptive-patient-behaviors-are-t512139/

Nurses have an obligation to chart objectively. When behaviors and attitudes need to be described, though, we don't always have the vocabulary on hand to chart an accurate, …

Do Not Use List Fact Sheet | The Joint Commission

https://www.jointcommission.org/resources/news-and-multimedia/fact-sheets/facts-about-do-not-use-list/

It may not be used in medication orders or other medication-related documentation. Development of the "Do Not Use" List. In 2001, The Joint Commission issued a Sentinel …

Consequences of Incomplete Patient Documentation - Lorman

https://www.lorman.com/resources/consequences-of-incomplete-patient-documentation-17435

Patient documentation is an essential part of medical care. Paperwork is used to compile information on a certain person, the treatment he or she received and personal …

Poor Documentation: Why It Happens and How to Fix It - For The …

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 …

Inappropriate Medical Abbreviations - PubMed

https://pubmed.ncbi.nlm.nih.gov/30085548/

While initially, the abbreviations were limited to the writing of prescriptions, today, abbreviations have become very common in all aspects of medical documentation. …

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