CASE 4-6 Alteration of Patient Record A patient was admitted to the…

Question Answered step-by-step CASE 4-6 Alteration of Patient Record A patient was admitted to the… CASE 4-6 Alteration of Patient RecordA patient was admitted to the hospital’s ambulatory surgery unit for surgical removal of 4 impacted wisdom teeth. As required, a staff internist did a history and physical (H&P) examination prior to admission. The dental surgeon removed the wisdom teeth and administered penicillin intramuscularly as a prophylactic. The patient had an immediate and violent reaction. After an extensive stay in the intensive care unit (ICU), the patient was discharged. On routine discharge analysis, the HIM clerk found several deficiencies requiring physician completion. During this analysis of the record, the clerk observed that the H&P stated “no known allergies.” As she was filing the ambulatory surgery record in the patient’s file folder, she noticed that the previous encounter had ALLERGIC TO PENICILLIN stamped in red letters on the visit cover sheet. She placed the record in the incomplete chart area for completion. When reanalyzing the chart a few days later, she saw that the H&P had been altered to read “patient denies any drug allergies.” She took the record to the HIM director, who called the hospital attorney. The patient filed a malpractice suit a few months later.1. What issues are involved in this situation?2. What process should be implemented to prevent this problem from happening again?3. What if the rate charged for the removal of the wisdom teeth was changed and did not agree to the claim filed? What are the issued involved with this situation? Health Science Science Nursing Share QuestionEmailCopy link Comments (0)

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