Poor documentation: The consequences

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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.