How to Ensure Accuracy During Medical Record Documentation

Accuracy is important in any kind of business documentation, and it is of increased importance when it comes to medical documentation. The safety of the patient, appropriateness of care provided, and further care planning all depend entirely on the accuracy of the documentation. That is why accuracy and reliability are the main features to look for in your medical transcription services provider. Medical records are a combination of both self-reported patient information and the physician’s notes on diagnosis, care and treatment given to the patient. Complete and accurate medical records facilitate smooth communication between providers, patients and payers about patient health status, treatment planning, delivery of care and preventive health services.

Medical Record Documentation

What are the common medical errors that lead to unreliable healthcare documentation?

  • Incomplete or missing data
  • Unnecessary blank space in forms within the medical records
  • Misplaced medical documentation
  • Not entering new medical conditions or symptoms
  • Misuse of copy and paste function in the EHR
  • Errors due to illegible physician’s handwriting or misunderstood dictation
  • Entry in wrong charts of files
  • Duplication of medical records
  • Failure to document omitted treatments/medications

How can providers avoid medical errors?

  • Eliminate shortcuts like copy paste in electronic medical records
  • Avoid usage of vague terms
  • Avoid unnecessary comments
  • Use the patient’s own words and gestures if possible
  • If you find mistakes, then take sincere effort to correct it
  • Avoid delay in documentation
  • Ensure your handwriting is clear and legible
  • Ensure that you are entering data in the correct patient records
  • Don’t insert new notes or delete an entry
  • Avoid documenting treatments and medications before they are completed
  • If the notes are dictated and transcribed by a third party, review the same for transcription errors and ensure that entries are signed before they are added to the patient’s record.

How can you ensure that the medical documentation is completed in a timely manner?

  • Conduct chart audits regularly: This is a great way to monitor how physicians are complying with the standard of accurate documentation, especially in group practices, ASCs and so on. You can hire an external company to conduct the chart audit. External chart audits will help increase awareness among physicians and other clinical staff.
  • Assign a staff member to track the medical records: You can assign a staff member to ensure that physicians are signing orders in patients’ medical records in a timely manner.
  • Invest in good Health IT solutions: This will pay off in the long run by enabling improved patient care, interoperability across the healthcare spectrum, and streamlined processes including complete and comprehensive medical documentation.

Physicians and healthcare organizations outsourcing medical transcription must be careful to partner with a reliable service provider with a good track record. It is important to be constantly aware that anything that has not been documented has not been done, from a litigation point of view. Your medical documentation must be simple – the quality of the medical record reflects the quality of care delivered. It should provide a complete and accurate description of the patient’s medical history, which includes the medical conditions, diagnoses, the care and treatment provided, and the results of such treatments. Always remember that the medical record is also the most important piece of evidence in the successful defense of a medical professional liability claim. Ensure accurate, comprehensive, and timely documentation of all your patient encounters.