Page 11 - Risk Reduction Series - Documentation Essentials (Part One)
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SVMIC Risk Reduction Series: Documentation Essentials
Breakdown of Documentation Issues
Following are some common documentation issues that have
been identified through medical record audits that make it
difficult to defend the care provided:
• Using unclear or nonstandard abbreviations
• Correcting erroneous entries incorrectly
• Documenting information in multiple areas of the record
with discrepancies between locations (i.e, allergies,
immunizations, problem list)
• Lacking documentation of physician review of results of
lab or diagnostic studies
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