* It’s a legal document required by law and other regulatory bodies.
Documentation should be recorded for each specific encounter, Trites says. That’s because providers are paid for the work they perform in each encounter, and that includes part of the documentation, she says.When auditing the charts for my unit I would find the following type of errors: incomplete admission histories, incomplete assessments (nurses for some reason have an issue with checking pupils; they either leave it blank, do not put in the size of the pupils, or unfortunately sometimes they obviously “make it up”—if you are charting PERRL and the patient has only one eye you obviously did not check the pupils). The patient was admitted a fall and short term loss of consciousness. In reviewing the chart first of all I found that there was no documentation that this was done every 2 hours; secondly most of the time the part of the exam involving the pupils was not even addressed and if it was they did not always mark the size of the pupils.This patient also had significant ongoing nausea and vomiting that was not reported to the physician.This is, in essence, a form of clinical plagiarism with potentially deleterious consequences for the patient.” The errors can ripple outward into population health studies and other data mining.It can make tracking disease outbreaks harder, Gelzer says.As the patient’s health worsened, a hospital stay of days turned to weeks.But through the various tests and physician visits, the progress notes generated in the hospital’s electronic record system looked similar.* It’s often used for implementing quality improvement initiatives. Nursing 2013, 41 (4), 24-29 [iv]Austin, Sally JD, ADN, BGS. * It’s used for utilization review to help determine appropriate level of care for admission and to obtain reimbursement. * It’s the most credible evidence in legal proceedings on whether the care given to the patient met the legal standard of care.[iv] [iii] Austin, Sally JD, ADN, BGS. And so the auditor begins to wonder, how is the facility coding these records? How does it make sure it is submitting accurate claims?“From a medical-legal standpoint, what would a lawyer do when they saw this chart? “They are going to rip it apart.” Other misrepresentations are also facilitated through certain electronic documentation.