What are three examples of poor documentation practices in patient
records?
Why are these practices problematic?
Distinguish among the three examples you have given, stating why one is worse than the others.
1.
Incomplete Medical History
: If the patient’s medical history is not documented properly, it can lead to incorrect diagnoses and treatment plans. 2.
Illegible handwriting
: If the healthcare provider's handwriting is difficult to read, it can lead to errors in medication dosages or treatment plans. This can be especially dangerous in emergency situations.
3.
Lack of date and time stamps
: If the documentation does not include the date and time of the healthcare provider's actions, it can be difficult to determine when certain treatments were administered or when a patient's condition changed.
I think that an incomplete medical history is the worst one out of the three that I chose. If a patient has a history of allergies, but it is not documented, they may be given medication that could cause an adverse reaction.
