Problematic Areas Where Gaps in Documentation Occur
July 11, 2016

Problematic Areas Where Gaps in Documentation Occur

Abnormal vital signs. A significant deviation from what is considered to the patient’s normal requires an entry detailing what is being done about it. For example, deviations may be fever,

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The Medical Record: Your Best Defense – 3
July 4, 2016

The Medical Record: Your Best Defense – 3

The more clear you can make your entries in the medical record, the greater impact it will have on how your care is perceived to be rendered. For example: The medical record is the only written

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The Medical Record: Your Best Defense – 2
June 27, 2016

The Medical Record: Your Best Defense – 2

Your entries in the medical record are recognized as the evidence of adherence to or deviation from a standard of care provided to a patient. The practice of nursing has become more complex, with ...

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The Medical Record: Your Best Defense – 1
June 20, 2016

The Medical Record: Your Best Defense – 1

The entries made by a professional nurse in the patient’s clinical record are recognized as testimony in the courtroom. The complete medical record is identified as evidence in the courtroom. The ...

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