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Health, Medicine, Nursing
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06-u5-t-1-2 Assignment: Documentation and Regulatory Compliance (Essay Sample)


Documentation and Regulatory Compliance

The advanced practice nurse should understand the legal framework for documentation in the medical record. The federal and state governments afford patients protection from disclosure of health care information. The nurse must know how to document when he or she challenges a physician’s order to protect him or herself and maintain the safety of the patient. Incident reporting of an adverse patient occurrence must state objective findings and should not contain opinions or subjective information. Blame should not be included in an incident report. Confidential information that is mailed or shared with the institution's attorney may be considered attorney client privilege. Documents that are attorney client privilege are not discoverable by the suing party.


Topic 1: Documentation and Regulatory Compliance
Advantages of Charting by exception
* It is Less expensive
* The time for documentation is reduced
* There is a concise standard to follow that allows uniformity
* It shows all pt's condition through flow sheet format
* It allows abnormal status to be shown immediately
Disadvantages of Charting by exception
The first disadvantage is that the system requires predicted output that is difficult to determine. The second challenge is that the system cannot document wellness and prevents promoting nursing functions (Shaikh & Prabhu, 2009). Finally, the system allows the nurses to select what to record. Therefore, there is a possibility that a nurse may fail to document some important activities.
How to Correct Mistakes in a Medical Chart and the Format for Documentation
The first step is to determine where the error is and the reason it needs to be corrected. It is provided that any information which has an impact on someone's treatment, ability to be contacted or diagnosis should be corrected. Hence, information concerning personal identity, payment or billing should be corrected (Edmondson, 1996). The next step is to contact the payer's office to enquire if a form for making amendments is available. The records need to be sent to the authenticated person if they are available. Another step is to make a copy of the record then correct the error by striking a line over the wrong information and making the correction through writing. In case, the correction is invalid then the form should be accompanied by a letter when sending it back. Finally, make a copy of every page that you have put together and send them back including the letter if any.
The Type of APO to be Reported and the how APO is Perceived in Courts
An example of adverse patient occurrence is caring for patients with diabetes. The patients need to be monitored closely throughout the care process (Morrison, 2001). However, APO is seen as evidence in court in case a patient's health deteriorates and the patient deci

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