REPORT OF AHIMA JOURNAL Englis 2 for MRHI students

ARTICLE
August 7, 2017 KAI, ZAEN 1
SOURCE
Butler, Mary. 2015. Preventing Healthcares Top Four Documentation
Disasters. Journal of AHIMA, Vol. 86, no. 7 pp. 18-23

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INTRODUCTION
Background:
Clinical documentation influence the number of hours a resident
physician takes in their work.
Case:
in 1984 Libby Zion a New York college student was admitted to
Manhattan emergency room with a high fever and aggitation. After
consulting with her family physician, the residents who evaluated Zion
in the ER administered a sedative and painkiller. But the caregiver did
not know she was taking anti-depressant that was dangerously
contradicted with the drugs the physicians gave her in the ER, because
Zion did not disclose the information at the point of care. The drug
combination ultimately proved fatal and Zion died from cardiac
arrest.

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 PROBLEM
This case is a caution for physicians in the ER to have full, up-to-date
medical histories in the right time. Because incomplete patient records
can have disastrous consequences.

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AIM
to recognize frequent documentation errors and put procedures in
place in order to prevent documentation disaster

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FOUR DOCUMENTATION MISTAKES:
1. Mixed messages from a physician vis a vis misunderstood
dictation or illegible handwriting
2. Misuse of copy and paste or copy forward functions in the
electronic health record
3. Incomplete or missing documentation
4. Misplaced documentation

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ERROR 1: MIXED MESSAGES FROM A
PHYSICIAN VIS A VIS MISUNDERSTOOD
DICTATION OR ILLEGIBLE HANDWRITING

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ERROR 2: MISUSE OF COPY AND PASTE OR
COPY FORWARD FUNCTIONS IN THE
ELECTRONIC HEALTH RECORD

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ERROR 3: INCOMPLETE OR MISSING
DOCUMENTATION

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ERROR 4: MISPLACED DOCUMENTATION

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SOLUTIONS
1. Preparation the best way to avois or manage disaster
2. Formalize efforts with a steering committee
3. Measure progress to sustain momentum
4. Dont make it all about the money
5. Spice up your program with PEPPER, programs for
evaluating payments patterns electronic reports

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SOLUTION 1: PREPARATION THE BEST
WAY TO AVOID OR MANAGE DISASTER

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SOLUTION 2: FORMALIZE EFFORTS WITH A
STEERING COMMITTEE

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SOLUTION 3: MEASURE PROGRESS TO
SUSTAIN MOMENTUM

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SOLUTION 4: DONT MAKE IT ALL ABOUT
THE MONEY

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SOLUTION 5: SPICE UP YOUR PROGRAM WITH
PEPPER, PROGRAMS FOR EVALUATING
PAYMENTS PATTERNS ELECTRONIC REPORTS

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COUNCLUSION AND COMMENT

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