Wait a second!
More handpicked essays just for you.
More handpicked essays just for you.
Medical terminology 2
Medical terminology fundamental
Medical terminology 2
Don’t take our word for it - see why 10 million students trust us with their essay needs.
Recommended: Medical terminology 2
To those unfamiliar with medical records, review of documentation can be a challenge. Medical records include many abbreviations and medical terminology composed of Latin and Greek terms. Some abbreviations, such as PT and DC, have more than one meaning. Not much attention is paid to punctuation and grammar in medical records and spelling errors can make them difficult to read. Legal nurse consultants play a pivotal role not only in translating medical records but in identifying their legal significance, including standards of care, causation and damages. But even LNCs can have trouble interpreting records when the handwritten documentation is illegible.
As nurses, we've all had to deal with physicians and others who have really bad handwriting. In a clinical situation, the nurse can speak with the physician to ask for clarification of, say, orders that are illegible. It's not as easy once a lawsuit is being contemplated or has been filed. In-house and independent LNCs may not be able to informally clarify records with treaters depending on the circumstances of the case and whether the LNCs are working for the plaintiff or defense. To maintain their objectivity, expert LNCs never speak with non-client treaters.
Deciphering horrible handwriting from medical records is a skill that many legal nurse consultants learn through trial and error. This discussion focuses on physician handwriting but the principles apply to other types of health care providers as well. Here are some tips to help new LNCs who are trying to figure out illegible handwriting.
Use your judgment deciding how much time to spend deciphering bad handwriting. All medical records are important but some are more so than others. For example, it may not be ...
... middle of paper ...
...iter's notes in one sitting. Sometimes you'll be able to read words in a later note which will enable you to understand earlier notes.
Conversely,it may help to let the task of deciphering sit for a day or two if possible. Sometimes words that eluded you earlier will pop out at you after a few days.
Use the process of "fresh eyes." If you have access to another legal nurse consultant, ask her or him to view the problematic handwriting and give you suggestions.
Even using these principles, there may still be some illegible documents or portions of documents that you will be unable to interpret. When this occurs, tell the attorney about the indecipherable notes and the potential significance of the notes. The attorney can then decide to depose the treater or get a transcript of the treater's notes, depending on the circumstances and specifics of the case.
During the 1980’s and 90’s there were many studies done that showed that medical errors were occurring in inpatient and outpatient settings at a very high rate. Computer Provider Order Entry (CPOE) systems were designed to reduce or eliminate mistakes made by using hand written orders. The CPOE system allows users to directly enter their orders into the system on computers which are then sent directly to the healthcare providers that will be implementing the orders. Previously orders were placed by writing on order sheets on patient charts. This was sometimes done by the doctor or by a nurse acting on behalf of the doctor. Order sheets were then signed by the doctor and then the information was input into the patient’s record. This left room for error due to misreading bad handwriting, confusing medications with similar names, etc.
Health Information Management (HIM) professional: Will expect that the healthcare providers are honest, accurate in their diagnoses, and the charges are legal, fair, and correspond to services rendered on the given day. All inaccuracies must be corrected as soon as discovered to inspire confidence in the HIM professional, the facility, and all the organization’s employees. All stakeholders depend upon the HIM professional to maintain the accuracy, privacy and security of the patient’s medical charts, and thereby secure the reputation of the facility and welfare of the patients.
...ting legibly is the biggest concern. Having legible writing makes the whole operation of the radiology unit flow together. If the writing isn’t legible then it could cause the whole process to stop. Having the process stop isn’t good. It causes the process to be slower and risking peoples lives. For example, the x-rays can show blood flow. Having a very quick process could save someone’s life if they were bleeding out and needed a fast x-ray of where the bleeding was coming from and how it could be stopped. Having the writing be very clear and legible lives can be saved and make he process easy for the technician, radiologist, and physician.
Mrs. Ard brought a wrongful death law suit against the hospital (Pozgar, 2014). The original verdict found in favor of Mrs. Ard, but the hospital appealed the court’s ruling (Pozgar, 2014). During the course of the appeal, an investigation of the records showed no documentation, by a nurse; of a visit to Mr. Ard during the time that Mrs. Ard stated she attempted to contact a nurse (Pozgar, 2014). The nurse on duty stated that she did check on Mr. Ard during that time; however, there were no notes in the patient’s chart to backup the claim that Mr. Ard had been checked on (Pozgar, 2014). One expert in nursing, Ms. Krebs, agreed that there was a failure in the treatment of Mr. Ard by the nurse on duty (Pozgar, 2014). ...
However, for any medical record to serve the purpose for which it is meant for, it has to be “contemporaneous, unambiguous, legible and accurate” (Dimond, 2005). Accuracy of records could be described as the most important factor when it comes to record keeping practice in nursing. This is because accuracy in nursing records and documentation provides a real timeline information of the various stages of care provision. Prid...
The use of abbreviations shortens length of many words thus really help healthcare professionals in saving time spent in writing notes. Abbreviations however do not always provide positive contributions due to misconceptions, misunderstandings, and misinterpretations leading to commitment of errors in the practice. Similarities in abbreviations for instance could root to a grave mistake. For instance the q.d. which an inscriber would like to indicate as every day could be erroneously interpreted as q.i.d. which means four times a day. Such error could result to over dosage when a certain medication is taken four times in a day instead of just once. Though some abbreviations can be easily understood clearly and exactly as to what meaning they communicate, the use of abbreviations generally invite error potentials particularly the error-prone abbreviations (ISMP, 2007) which can be best avoided by eliminating abbreviations.
An essential part of a neurosurgeon’s role is to correctly handle the documentation of data pertaining to their patients' treatment. This specific data records contains treatment programs and schedules, medication plans, diagnosis details and any other analysis information pertaining to their patient’s health.
On a daily basis, I will have to engage in charting and documentation writing to ensure patients receive the best possible care. Charting will involve patient identification, legal forms, observation, and progress notes. Documentation must be factual with objective information about the patients’ behaviors. Accuracy and conciseness are crucial characteristics of documentation in the nursing profession so that other medical professionals can quickly read over the information (Sacramento State,
At the end of the day, physicians routinely record their patient notes into a tape recorder or other recording device, depositing the resulting medium at the hospital's transcription department. Since most in-house records departments are not 24/7 operations, there is no action on the patient data until the next morning, when the transcription staff types up the information in the tapes. When the transcription is complete, the st...
chartings in the medical record of a patient, taking the patients vitals and reporting abnormal to
It should be written in either black or blue ink. Each provider should always document the evaluation and results of every visit during the visit. It is prohibited to pre-date or backdate an entry. If there is to be a mistake written in a wrong patients file it should be dated and signed by the person that is revising the file; this shows proof that it was corrected.. The purpose of a medical record is for the health care provider to provide care to the individual patient.
I have reviewed the HR issues surrounding a recent case concerning an impaired nurse providing care to a critically ill patient. The issues surround three employees, Nurse Albert, Nurse Cusack, and Nurse Minor. The Case raises concern for the potential of other incidents. Nurse Albert is described as very conscientious nurse. Her actions may not violate HR policy but raise questions of ethical conduct and professionalism.
Data and information are integrated into each step of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. ("Nursing Excellence." Nursing Informatics 101. Web. 19 Nov. 2014.) Following this process, nursing informatics personnel can organize and set each file and record accordingly based on the care process. Since health care providers communicate primarily through the notes they write in a patient’s chart, nurse informaticists seek to continually improve the speed, timeliness and accuracy of patient charting. Working with the accurate information is key to nurses in all fields of the spectrum. It is beneficial to the health care providers that information is precise and up-to-date so the care will be more than sufficient. When health workers have access to more up-to-date, complete patient notes, they can make better decisions about a patient’s care and use the appropriate resources to better help the quality of the patient’s care doctors can
The purpose of this paper is to highlight the ethical challenges that could be experienced by professional nurses. To set the context of discussion, background is provided in relation to a professional nurse signing her name to a preprinted prescription form as asked by a physician and its relevance of how the board of nursing should find in such a case. The possible ethical challenges for the nurse is the implication of being charged with professional misconduct. The paper focuses mainly on issues relevant to professional misconduct by the nurse and physician.
• Handwriting interpretation errors are estimated to cause 9% of all medication errors. Although electronic prescribing (e-Rx) is finally well underway in the United States, it has for several years been the norm in many European countries. As recommended by the federal government and other national health care improvement organizations, the use of electronic prescribing applications in pediatric practice should be encouraged. The Institute of Medicine has recommended that all prescriptions be written electronically by the year 2010. It is estimated that 20% of U.