Failure to obtain clinical records on time during unexpected circumstances like

Failure to obtain clinical records on time during

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Failure to obtain clinical records on time during unexpected circumstances like surgical emergencies Establish effective organizational tools to maintain, protect, and access medical records 3. Comprehensivenes s Data comprehensiveness certifies all required data elements that should be collected throughout the health record are documented Loss of important files affect quality documentation especially for reimbursement Gather, analyze, and organize all the data documented throughout the course of the health record 4. Consistency Patient data that is reliable and the same across the entire patient encounter Erroneous drug prescriptions that do not support the diagnosis Ensure that the data documented in the medical record is accurate and consistent 5. Currency Data that stays current and up to date Health of a patient can be seriously affected; for example, if the patient developed an allergy to a certain drug and it was not reported to the medical record Review that the medical data remains updated
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6. Definition Data elements that are clearly defined to guarantee that all individuals using and collecting the data will understand the meaning of that data element Incomplete medical data due to lack of understanding of its meaning Educate himself/herself and other
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  • Fall '19
  • Caterina Whitus
  • Physical examination

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