The accuracy of a long-term care facility's medical records system requires effective training, ongoing education, and great communication among the staff that handle the records. Staff need to be constantly aware of issues that could impinge on that accuracy and have strategies in place to ensure they have adequate time to document all events that occur-from a fall to a prescription drug reaction to weight gain or loss.
Some of the issues that may prevent accurate documentation include:
Staffing shortages. A facility must have an adequate resident to nursing staff ratio in order to operate effectively. When staff is short, the nurses and aides left to take care of the residents often do not have adequate time to accurately complete a resident's medical record or file an incident report.
Some of the issues that may prevent accurate documentation include:
Staffing shortages. A facility must have an adequate resident to nursing staff ratio in order to operate effectively. When staff is short, the nurses and aides left to take care of the residents often do not have adequate time to accurately complete a resident's medical record or file an incident report.