Question

Analyze the case study below. Based best practices from the Integrity of the Medical Records article, identify the issues and resolutions so that this does not occur in the future.

A patient was seen by a clinician on September 1, 2013, just before lunch. Once the patient was examined, the clinician got sidetracked and was not able to enter his note on the date the patient was seen. During the visit, the patient discussed a possible reaction to a prescribed medication. On September 5, 2013, the clinician was back on duty after a long weekend; upon review of the record, he realized that he did not make an entry on September 1, 2013.

As the clinician began documenting, he decided that he wanted the date to reflect the actual date the patient was seen. He changed the date to September 1, 2013, at 11:30 a.m. He proceeded to enter the documentation as best he could. He remembered and documented the symptoms the patient described surrounding the potential medication reaction.

When another clinician reviewed the record, he saw the new note. This second clinician worked over the weekend and did not recall seeing this information but sees now that the date displayed is September 1, 2013, at 11:30 a.m. This alarmed the clinician, as he prescribed the medication that the patient had indicated a possible reaction to in the past.

Answer 1

According to case study the issue is -a clinician forgotten to mention the date in medical record due to some distraction or sidetracted. these type of error are possible in human life(or a type of human error) because in clinician duty there are lot of distraction and sometime they missed something.

Electronic health records (EHRs)------it can be a best solution for it because in EHR system time, date and login member is autometically recorded or saved. In this a electronic signature also pasting or submitting this give us an actual recording and a feasible data for medical record.

Electronic documentation tools offer many features that are designed to increase both the quality and the utility of clinical documentation, enhancing communication between all healthcare providers

if you have any query we will discuss in comment section otherwise plese like thanks