Altering documentation in patient records can have serious consequences, including allegations of fraud and professional misconduct — and it also can make malpractice claims difficult to defend. Yet, mistakes happen and situations undoubtedly will occur that require healthcare providers to make corrections, addendums, or late entries in patient records.
Read moreAllegations associated with diagnostic errors — i.e., wrong diagnoses, delayed diagnoses, and missed diagnoses — are a top cause of malpractice lawsuits. A number of risk factors can lead to diagnostic errors, including issues related to documentation of clinical care.
Read moreElectronic health records (EHRs) have transformed the ways in which healthcare providers work and communicate. These systems have been both extolled and criticized over the years as their use in hospitals, healthcare practices, and other healthcare facilities has become ubiquitous.
Read moreDocumentation is paramount in healthcare delivery because it memorializes patient care, facilitates communication among caregivers, forms the basis for coding and billing, provides data pertinent to quality improvement, and may provide information that is critical to the defense of a legal action. Documentation also serves a crucial role in the disclosure of unanticipated outcomes, such as medical errors, medical mismanagement, system errors, or other unforeseen situations that lead to patient harm.
Read moreWorking to minimize medication errors and adverse drug events (ADEs) is a worthwhile goal for healthcare practices. Eliminating all errors and ADEs, however, is unlikely due to the fast-paced nature of the healthcare environment, the numerous demands providers face, and the staggering number of medications on the market.
Read moreObstructive sleep apnea (OSA) is an insidious condition that can result in significant healthcare-acquired injuries if it is not properly recognized and treated. This case illustrates what can happen when a patient's treating physicians do not address and adequately communicate information about OSA to other members of the healthcare team — in this case, the surgery recovery staff.
Read moreWith a turn of the calendar year, 2022 will likely usher in the most significant changes to the HIPAA Privacy Rule in almost a decade. These changes will come on the heels of several years of information-gathering, proposals, and public comments, which kicked off December 2018 when the U.S. Department of Health and Human Services (HHS) Office for Civil Rights issued a request for information on HIPAA rules. HHS subsequently released and published the Notice of Proposed Rulemaking (NPRM) in December 2020 and January 2021, respectively. A public comment period on the NPRM followed, which concluded May 6, 2021.1
Read moreMany healthcare providers and staff members find that text messaging provides quick access to the information they need to make healthcare decisions and is a convenient method for communicating with other providers and patients. Yet, healthcare providers and staff members need to be cognizant of HIPAA Privacy and Security Rules when using text messaging to avoid violating them.
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