[Solved]: A patient was seen by a clinician on September 1,…

A patient was seen by a clinician on September 1, 2013, just before lunch. Once the patient was examined, the clinician got sidetracked and was not able to enter his note on the date the patient was seen. During the visit, the patient discussed a possible reaction to a prescribed medication. On September 5, 2013, the clinician was back on duty after a long weekend; upon review of the record, he realized that he did not make an entry on September 1, 2013. As the clinician began documenting, he decided that he wanted the date to reflect the actual date the patient was seen. He changed the date to September 1, 2013, at 11:30 a.m. He proceeded to enter the documentation as best he could. He remembered and documented the symptoms the patient described surrounding the potential medication reaction. When another clinician reviewed the record, he saw the new note. This second clinician worked over the weekend and did not recall seeing this information but sees now that the date displayed is September 1, 2013, at 11:30 a.m. This alarmed the clinician, as he prescribed the medication that the patient had indicated a possible reaction to in the past. Discussion Questions: How does Point of Care documentation play a role in this scenario? What procedures can be established to ensure that medication reactions described by a patient are documented in an accurate and timely manner to prevent medication errors and negative medication reactions? What time-safe rules can be established to prevent staff from being able to enter data after a subsequent visit has been documented without systematic alerts to notify specific end users of a late entry or a change in documentation?