Illegible Medical Records
While going over a patient's chart, you notice that there are several comments and markings that are illegible.
What should you do in this situation? Explain.
In what ways do you think poor legibility impacts different users of medical records?
What are some of the legal ramifications of illegible entries?
Other than writing more clearly, what are ways that you can suggest to help improve legibility?
https://brainmass.com/health-sciences/health-care-ethics/illegible-medical-records-354589
Solution Preview
The best procedure to follow when you find illegible notes on a medical record is to go to the source- ask the doctor that wrote them. Doctors should be asked to re-write a note for clarity or dictate the note. You should never "guess" what it is written. Illegible handwritten notes can affect all levels of patient care. For example, pharmacists have to read the physician`s prescription to dispense and nurses need to understand it to administer the correct medication to patients (Institute of Medicine, 2000). Patients also need to understand the instructions to follow treatment. The Centers for Medicare and ...
Solution Summary
The solution discusses the options available when illegible notes or comments are found on a patient's chart. It includes how these illegibles notes or comments can impact diferent users of the medical records, legal ramifications and solutions to prevent illegible notes on chart.
Advantages of Computer-Based Medical Records
The office manager of the physician practice office where you work has included you on a task team to assess the pros and cons of moving some of the medical record information from paper-based to computer-based systems. You have been assigned to research HIPAA Privacy and Security Rules and identify those that could impact this transition.
Compare the relative advantages and disadvantages of computer - versus paper-based medical records.
Identify techniques for storing and maintaining medical records.
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