QA87 Problem with clinical documentation without injury or harm

International Classification of Diseases for Mortality and Morbidity Statistics, 11th Revision, v2024-01

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  (PL14.7)

synonyms

• Problem with clinical documentation without injury or harm
• documentation on wrong patient without documented injury or harm
• incomplete documentation without documented injury or harm
• incorrect documentation identified as inconsistent with other source without documented injury or harm

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