Record Legibility Concerns

Wednesday, October 03, 2012 at 2:45:46 PM

A recent Department of Health/CMS survey found concerns with medical record legibility. Illegibility poses serious risks to patient care and communication with the health care team, drains valuable healthcare resources, jeopardizes optimal reimbursement, and carries potentially disastrous legal ramifications for healthcare organizations. Documentation in the patient record must be clearly readable to support all uses. The Medical Staff Medical Records Committee will be reviewing potential plans to identify outliers and to correct problems with legibility for signatures and notes.

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