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Major types of medical record errors and how to address them

Medical records often contain mistakes in medical history, diagnosis, test results, and medications. A study, available here, found that one in five patients who reviewed an electronic health record reported finding a mistake, and 40% perceived the mistake as serious.  This is alarming and should be a concern to attorneys that handle personal injury cases.  When presenting or trying to settle a claim with an insurance carrier, or litigating a case, it is very important to rely upon error-free medical records.  One mistake in a client’s medical records could result in an issue that can derail a case.

Common Types of Documentation Errors:

Medical documentation errors can be of various kinds. Shortlisting and determining some of the frequently occurring errors can help to identify the mistakes.. Below are some of the many frequently occurring medical documentation errors:

  1. Dictation errors & Illegible Handwriting

In today’s world, hospitals use EHRs (Electronic Health Records) to capture and decipher the messages dictated by physicians. However, transcription errors, such as mixing up numerical values or omission of a part of a medical term,  commonly occurs. Physicians also dictate notes into the wrong patient’s file when in a hurry.

Similarly, physicians also use abbreviations understood only by them instead of common abbreviations leading to errors while transcription. Nurses tend to misunderstand similar sounding medications when dictated by physicians on the phone. To reduce such errors hospitals have come up with a list of frequently confused medical terminologies and medications.

  1. Careless Copy & Paste

Every EHR allows its user to re-use the detailed narrative portion of the health record either partly or entirely. This can be read by other users or providers later. Incorrect use of copy + paste can cause patient harm as it makes it difficult to understand the progression and resolution of illness.

  1. Misplaced Documentation

Physicians not happy with their EHR setup start using their own templates. This may lead to misplaced medical documentation and information. For example, progress notes ending up in the procedure notes section. Medical documentation such as lab reports, radiology reports being misplaced can cause physicians and nurses to work with incomplete information causing grave danger to the patient.

Addressing Errors In Medical Documentation

A close review of the medical records by someone with experience will identify any errors in the documentation and information presented. Once an error is identified, the patient can ask the healthcare provider to update the records so that it accurately reflects the patient’s medical information.  Under HIPAA, a patient has the right to request that a doctor amend medical records, and it is up to the provider whether an amendment will be made.  Either way, the doctor must respond to the request.   After the revisions are made, the patient’s attorney can obtain a copy and rely upon them when submitting a claim to the insurance carrier or litigating a case.

At AcroDocz our team is experienced in the retrieval, review and summary of medical records and bills, and can identify errors or omission of information in order to ensure that the records contain all of the relevant and necessary patient information.

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