Medical Documentation Errors can hamper the accurate documentation of patient details, treatment plans, medications prescribed, and medical history which, is an important part of patient care. It is very important to submit error free documents while dealing legally to get a settlement from a provider. Although electronic deciphering, maintenance, and retrieval of records have become mainstream nowadays, the documentation is inevitably kept error-free.
Common Types of Documentation Errors:
Medical documentation errors can be of various kinds. Shortlisting and determining some of the frequently occurring errors can help reduce the time and money spent on unnecessary paperwork. Below are some of the many frequently occurring medical documentation errors:
1. Dictation errors & Illegible Handwriting
In today’s world, hospitals use EHRs to capture and decipher the messages dictated by physicians. Despite which common transcription errors such as typing “hyper” instead of “hypo” and “he” instead of “she” commonly occurs. Physicians can 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.
2. 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. Loss of such data can either result in over or under reimbursements of claims and send red flags to auditors looking for fraud.
3. Missing/Incomplete Documentation
When documentation is missing or incomplete, it could lead to calls from Medicare auditors or insurance agents looking for missing or incomplete documentation. Most of the important medical details are lost in the documentation charts as physicians use ambiguous terms such as “unspecified” or “not otherwise specified”. Such missing documentation can cause patient harm and negatively impact physician reimbursements.
4. Misplaced Documentation
Physicians not happy with their EHR setup start using their templates. This may lead to misplaced medical documentation. 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.
Physicians and nurses should be trained to write clear notes and adhere to common abbreviations, terminologies, and templates while recording patient information. Medical records documentation specialists should ensure that all documents, reports are submitted before claims submission to receive maximum reimbursements. A better solution to get error-free documents would be outsourcing the retrieval and summarizing of medical documents to medical records retrieval services providers like AcroDocz.
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