contestada

1. Since the director is a friend of the physician and knows he should have been more specific in his documentation, should the HIM director allow the physician access to the record to add the documentation? Why or why not?

Respuesta :

The "HIM" director must allow the physician access to the record to add the documentation because if he doesn't then the record will not be a good clinical record which leads to the misinformation of healthcare professionals and patients. Every entry in the record must be dated and timed respectively.

Explanation:

  • Clinical record keeping is one of the most important aspects of maintaining professional practice and delivering quality healthcare.
  • Hence these records must be updated by all the members of the multi-disciplinary team involving physicians, nurses, surgeons, etc.
  • By documenting the medical notes one is maintaining the records for future reference.
  • Poor clinical records lead to increase of medico-legal risks.
  • Misinformation and poor quality of records put the patient's care in jeopardy.