Unit 5 Topic 1 Documentation and Regulatory Compliance, assignment help

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Topic 1: Documentation and Regulatory Compliance

Based on the information you have learned in the course so far and the readings, analyze the advantages and disadvantages of charting by exception when faced with a malpractice lawsuit. Discuss how you would correct mistakes in a medical chart and the formatting of your documentation when witnessing an adverse patient occurrence (APO). What APOs have to be reported in your state? How would charting corrections be perceived in a court of law? What are the implications for handling of forensic issues?

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Running head: DOCUMENTATION AND REGULATORY COMPLIANCE

Documentation and Regulatory Compliance
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DOCUMENTATION AND REGULATORY COMPLIANCE
Documentation and regulatory compliance
Charting by exception involves documentation of anomalies. In this method, clearly
defined values and expectations of various observations and diagnoses are created through a
chart developed in advance. Unlike most other documentations where a practitioner records
all the observations, only the anomalies or exceptions are recorded in the chart. In a condition
such as a cardiac exam, a patient’s sinus rhythm is only recorded if their condition falls
outside the normal range or, in this case, 60-80 pulses per minute. This happens if the
anomaly is either above or below the normal. According to Murphy (2003), this form of
documentation has become popular since it saves a lot of time which is required to optimize
service delivery in a healthcare facility.
Charting by exception has its benefits and disadvantages in the healthcare practice. It
is common for healthcare practit...


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