Poor Documentation Practices

The purpose of the health record is to document patient treatment and continuity of care and provide a place where the health care team records information that can be communicated to one another and used to make health care decisions. It also serves as the legal record for patient care.

In order for the record to fully serve its purpose, good documentation practices are critical. Describe some examples of poor documentation practices in patient records. Explain why these practices are problematic and how they could impact the validity of the legal record. Research and find a documented case to support your perspective on problematic documentation practices with the health record.

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