{"id":387,"date":"2020-06-18T19:24:14","date_gmt":"2020-06-18T19:24:14","guid":{"rendered":"https:\/\/www.acrodocz.com\/?p=387"},"modified":"2022-02-23T05:00:26","modified_gmt":"2022-02-23T05:00:26","slug":"major-types-of-medical-record-errors-and-how-to-address-them","status":"publish","type":"post","link":"https:\/\/www.acrodocz.com\/major-types-of-medical-record-errors-and-how-to-address-them\/","title":{"rendered":"Medical record errors and how to address them"},"content":{"rendered":"

Medical records often contain mistakes in medical history, diagnosis, test results, and medications. A study, available\u00a0here<\/a>, found that one in five patients who reviewed an electronic health record reported finding a mistake, and 40% perceived the mistake as serious. \u00a0This is alarming and should be a concern to attorneys that handle personal injury cases.<\/p>\n

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. \u00a0One mistake in a client\u2019s medical records could result in an issue that can derail a case.<\/p>\n

Common Types of Documentation Errors:<\/p>\n

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:<\/p>\n

    \n
  1. Dictation errors & Illegible Handwriting<\/li>\n<\/ol>\n

    In today\u2019s world, hospitals use\u00a0EHRs<\/a>\u00a0(Electronic Health Records)<\/u>\u00a0to 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, \u00a0commonly occurs. Physicians also dictate notes into the wrong patient\u2019s file when in a hurry.<\/p>\n

    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.<\/p>\n

      \n
    1. Careless Copy & Paste<\/li>\n<\/ol>\n

      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.<\/p>\n

        \n
      1. Misplaced Documentation<\/li>\n<\/ol>\n

        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.<\/p>\n

        Addressing Errors In Medical Documentation<\/u><\/strong><\/p>\n

        AcroDocz reviews and summarizes medical records and presents all relevant information in a chronology with the records hyperlinked and bookmarked.\u00a0 The chronology should be reviewed by the client to ensure that all of the information contained in the medical records are accurate. Once an error is identified, the client can ask the healthcare provider to update the records so that it accurately reflects the patient\u2019s medical information.\u00a0 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.\u00a0 Either way, the doctor must respond to the request.\u00a0 \u00a0After the revisions are made, the client\u2019s attorney can obtain a copy and rely upon them when submitting a claim to the insurance carrier or litigating a case.<\/p>\n

        Acrodocz brings you a team with extensive experience retrieving, organizing, reviewing and summarizing medical records.\u00a0 Our pricing is straightforward and there are no hidden fees. To learn more about our services, please call us at (786) 633-3100 or email us at info@acrodocz.com<\/a>.<\/p>\n","protected":false},"excerpt":{"rendered":"

        Medical documentations include various kinds of errors. Shortlisting and determining some of the frequently occurring errors can help reduce the time and money spent on unnecessary paperwork. Learn more about some of the frequently occurring errors.<\/p>\n","protected":false},"author":1,"featured_media":388,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_et_pb_use_builder":"","_et_pb_old_content":"","_et_gb_content_width":"","content-type":"","inline_featured_image":false,"footnotes":""},"categories":[11,21],"tags":[],"acf":[],"yoast_head":"\nMajor types of medical record errors and how to address them<\/title>\n<meta name=\"description\" content=\"Medical documentation errors can be of various kinds. 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