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Sidebar - The Chart Remembers
Statutes & Stethoscopes: Sidebar - The Chart Remembers.
A nursing home chart that looked perfect: turned every two hours, skin checked every shift, beautiful documentation. Then the audit trail showed a full week of repositioning entries typed in one afternoon, three days after a stage four pressure injury was found.
In this Sidebar I explain the two stories every electronic health record keeps: the note on the screen and the record of who wrote it, when, and what changed. We cover what an audit trail can show, how a proper late entry and addendum should look, how audit trails can also…
The skinny
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