HSM425

Consider the following scenarios and the questions they raise about data quality:

A late entry is written to supply information that was omitted at the time of the original entry. It should be done only if the person completing it has a total recall of the omission. For example, a nurse completed her charting on December 12, 2002, and forgot to note that the physician had talked with the patient. When she returned to work on December 13, she wrote a late entry for the day before and documented the physician's visit. The clinician must enter the current date and the documentation must be identified as a late entry including the date of the omission. Additionally, a late entry should be added as soon as possible.

A late entry cannot be used to supplement a record because of a negative clinical outcome that occurs after the original entry. For example, while a patient received an antibiotic for two days, the nurse charted nothing unusual. Yet, on the third day, the patient had an acute episode of shortness of breath and chest pain and died later that same day. At the time of death, documentation revealed that the patient had a dark red rash on his chest.

An investigation into the cause of death was conducted and all the nurses who provided care during the three days were interviewed and asked whether they had seen the rash prior to the patient's death. None of the nurses remembered the rash. However, one nurse wrote a late entry for each of the first two days that the patient was receiving the antibiotic stating that there was no rash on those days. This is an incorrect late entry. Her statement is part of the investigation conducted after the fact and was not an omission from her original entry [Schott, 2003, 23-24]. Assignment:

1) What should an organization do? 2) How does one create an environment that promotes data quality? 3) What are some of the problems associated with having poor-quality data? "Provide Reference"