Maintaining accurate medical records is crucial for healthcare professionals and medical entities to execute proper patient care without facing legal consequences. A medical record comprises a variety of documentation that includes a patient’s medical history, clinical diagnosis, treatments, pre and post-operative care, medications involved, etc. This documentation plays key role as evidence when a medical negligence case is filed.
Generally, a medical malpractice suit arises due to data breaches or in some form of medical negligence and errors in records. Some of the more common medical record documentation errors includes: inaccurate diagnostic results, transcription mistakes, overlooked medical records, incorrect medication instructions, documenting orders in the wrong chart, use of inappropriate abbreviations, etc.
This is the reason why organizations look for skilled professionals to carry out medical record documentation. However, errors in record documentation remain common.
A report from Becker Hospital stated that 70% of patients carry the wrong medical information. While some errors are harmless, others can be distressing or fatal. CNBC even highlighted that nearly 250,000 people in the U.S. die due to medical errors every year. The most common mistakes included medications, allergies, and discussions that did not happen.
It can be challenging to discover the consistent cause of errors and to provide a viable solution to minimize the chances of recurrence. But once the errors are recognized, learning and working towards preventing them can greatly improve patients’ safety. It is essential for healthcare organizations to establish a safety culture that focuses on improving the review techniques and seeing errors as a motivation to remedy their processes.
Ways to prevent errors in record documentation:
1. Focus on accurate entries: Accurately document patient’s medications, treatments, ongoing care for the reference of other medical professionals.
2. Look for small details: Omission or neglecting medical information should be avoided, as even minor details could help provide proper care for the patient. Try to cover all the incidents and treatments offered.
3. Prepare operative notes within 24 hours: It is crucial to prepare the operative notes right after the operation or procedure. It helps in the continuity of care when the patient is discharged.
4. Offer adequate training: Every medical organization should offer good training on handling proper medical record documentation without errors for their staff. It helps greatly to minimize risks.
5. Prevent demographic errors: This error can occur when two patients share the same name and can be overcome if the organization implements a system to identify words and medications quickly.
6. Be timely: Complete the medical records within a specific time. As mentioned earlier, get the operative notes signed within 24 hours and post-operative notes immediately after the procedure.
7. Legible transcripts: Physicians’ handwriting should be legible, and abbreviations should be clear to help document records without errors.
8. Provide proper steps to correct errors: An appropriate correction technique should be followed, such as making information legible, striking wrong entries, providing a reason for the mistake, and documenting accurate information.
9. Implement an EHR system: Healthcare with EHR can streamline and manage medical records effortlessly as it helps to track and change corrections once authenticated. Integrating it will allow avoiding severe damages.
10. Create forms: Make it easy for the patients to suggest changes in the medical records through form submissions.
11. Do not miss out on late entries: Create a separate procedure to document late entries to avoid missing any essential information. Record the details of a late entry and validate it.
12. Set time frames for omissions: Establishing time frames will help you maintain a proper schedule. Follow a monitoring method or review to ensure that the documentation is timely and properly administered.
13. Be responsive: Hospitals and healthcare professionals should respond quickly if any patient requests changes to their medical record information.
Once healthcare organizations start to streamline and control management activities appropriately it becomes easy to prevent errors. Though many organizations try to develop an in-house team to manage error-free documentation without giving space for data breaches, outsourcing stands as a cost-effective and convenient option.
Dedicated medical record companies like PreludeSys follow a comprehensive set of principles and techniques to process medical records reviews. With a scalable team, innate expertise, and security policies, we deliver the best customized medical record management solutions that help you lower the risk of lawsuits and improper treatments.
Contact our team to learn more about medical records management and documentation. We work with businesses like yours and can deliver the best service to help you concentrate on core competencies and reduce operational expenses.