Incomplete documentation in patient clinical records can cause your organization legal and settlement fees, cause you to lose your license, contribute to inaccurate statistical databases, cause lost revenue/reimbursement, and result in poor patient care by other healthcare team members. That's why every organization should ensure accurate and complete clinical documentation (at any cost).
If documentation is inaccurate:
- Researchers wouldn't be able to conduct patient-related studies
- Safe patient care is compromised due to a nurse's incomplete/inaccurate clinical chart
- Reimbursement/gross revenue is decreased
- Findings of fraud and abuse will lead to federal prosecution
Editor's note: The above excerpt is from the online course "Nursing CE Series: Nursing Documentation - Reduce Your Risk of Liability." For more information about our nursing resources, click here.