QA87
Problem with clinical documentation without injury or harm
Problema com a documentação clínica, sem lesão ou dano
CategoryDefinition
Documentation on wrong patient; incomplete documentation; incorrect documentation identified as inconsistent with other source, but without documented injury or harm to the patient.
Exclusions
- Problem associated with clinical documentation
Index Terms
Problem with clinical documentation without injury or harmdocumentation on wrong patient without documented injury or harmincomplete documentation without documented injury or harmincorrect documentation identified as inconsistent with other source without documented injury or harm