How to Reduce Risk of Errors in Electronic Medical Records

Though healthcare professionals strive to prevent documentation mistakes, errors can occur. It’s important that remedial action is taken when mistakes are identified. According to a research published in the Journal of Patient Safety, medication and diagnostic errors account for 90% of EHR errors. Using medical transcription services is a practical approach to reduce EHR mistakes. EHR-integrated transcription implies that the information is fed into the system in accordance with current rules and specifications.

6 Strategies to ensure correct Electronic Medical Records

• Choose a well-designed EHR system: A poorly-implemented EHR system can result in a number of problems, including challenges with collecting and managing clinical data, data sharing concerns, issues with alerting for hazards, such as harmful drug interactions, and interoperability issues. Simply put, an EHR should facilitate decision-making and workflow rather than making the process more difficult.
• Use data intuitively and employ risk-reduction techniques: Lowering the risk of medical errors requires an understanding of growing areas of risk inside an organization as well as trends in patient healthcare quality. When applied intuitively, data and metrics form the basis of a strategy that helps identify potential risk areas and potential hot spots for mistakes. EHRs must be used in conjunction with other risk-reduction strategies because they cannot solve issues on their own.
• Train staff on EHR use: User error can lead to medical mistakes, such as when staff members enter clinical data inaccurately. Training to reduce user errors includes putting in place the necessary safeguards to ensure the accuracy of the data submitted, as well as educating the employees on how to efficiently use the EHR’s data input interface.
• Record all actions taken: A record of an encounter is incomplete if important information is left out. When administering an evaluation, a physician or other healthcare provider may multitask, and this can lead to unintentionally forgetting to include a crucial piece of information. It is impossible to prove something if it was not documented in the record. Such omissions can lead to issues with patient care, billing, and compliance, and possibly result in legal action. All activity during a patient encounter should be recorded and reviewed before the record is signed by the physician.
• Avoid over-documentation: EHRs are so detailed that it could be tempting to fill out every area in the template. While accepting and enjoying the functionality of the system, make sure that there are always checks and balances in place. The most important thing is to constantly consider what is medically required. If the documentation meets medical necessity considerations, it may be possible to conclude that EHR documentation is accurate and that neither overcoding nor undercoding occurred.
• Perform periodic internal audits: Every practice, regardless of size, should carry out periodic internal EHR audits. These audits should be done in accordance with a compliance policy. Running reports can help find missing data and spot irregularities as soon as they occur. It is crucial to regularly go through compliance standards and documentation best practices with staff.

The electronic health record (EHR) is designed to manage medical information effectively and enhance patient care. However, documentation mistakes can jeopardize the accuracy of the data and impact on patient care and safety. Outsourcing medical transcription can help healthcare organizations deliver better care by streamlining the EHR documentation process.