Documentation integrity involves the accuracy of the complete health record.
It encompasses information governance, patient identification, authorship validation, amendments and record corrections as well as auditing the record for documentation validity. Unless documentation is completed appropriately, the integrity of the data may be questioned and the information deemed inaccurate—or possibly even perceived as fraudulent activity.
Without safeguards in place, records could reflect an inaccurate picture of the patient's visit, which potentially could cause a high level of risk exposure up to and including legal action.
This training will assist you and your staff on the do's and don'ts of documenting in a medical record which can lower your risk in the long run.