Medical Record Documentation – Take Care to Avoid these Common Errors

Medical Record Documentation

Healthcare providers are well aware that documenting each patient’s condition and history of care is crucial and medical transcription outsourcing plays an important role here. To ensure proper care, the information about the patient must be communicated to other caregiver’s in the team.

An incomplete or inaccurate patient record can compromise care and shows:

  • care was incomplete
  • there were gaps, indicating poor clinical care
  • lack of compliance with policies

Documentation errors (either commission or omission) result in improper medical advice being provided. By affecting care, poor documentation in patient clinical records can lead to allegations of negligence. It can also result in expensive, painful, and/or unnecessary diagnostic studies, billing mistakes, cause loss of reimbursement, and lead to charges of fraud and malpractice.

The first step to ensuring accurate and complete clinical documentation is recognizing the common errors that can occur and taking steps to prevent them.

  • Confusing Statements from a Physician Related to Misinterpreted Dictation or Transcription Errors: It is critical that a reliable medical transcription service provider handles the task of converting physician dictation into text. Patient’s medications, procedures, and activities and ongoing developments in treatment need to be accurately documented for the reference of other caregivers. Certified and trained medical transcriptionists are familiar with even difficult medical terminologies and conditions, which among other things, is necessary for dictation to be transcribed accurately and promptly.
  • Not Documenting Prior Treatment Events: Leaving out even small details of the treatment given to the patient across nursing shifts can have disastrous consequences. All incidents that occurred and treatment provided should be documented so that there is no room for doubt about the patient’s condition. The Nurse Service Organization (NS) recommends that nurses leverage hospital standard flow sheets in the patient’s EHR to document details of the treatment given to the patient.
  • Not Placing an Operative Note on the Chart Immediately after an Operation is Performed: The operative note should be dictated and signed within 24 hours of operation/procedure. This document records the operation that the patient had, what was found during the surgery, and the surgeon’s post-operative instructions. Having this information in the chart is crucial for continuity of care when patient is moved into the recovery room or discharged.
  • Medication Errors and Omissions: Medication errors can occur during prescribing, transcribing, dispensing and during administration. It is critical to record every medication given to the patient over the entire course of treatment-including the dose, route, and time of each administration. A 2017 study from the Pennsylvania Patient Safety Authority noted the EHR users are highly prone to making medication errors that negatively impact patient safety. Up to one third of mistakes were due to dose omissions, wrong dosage or over dosage, and extra dosages, according to the study. Many errors were also caused by improper documentation of medication instructions in the EHR errors. Errors were also caused when prescribers entered free-text instructions in the order comments field, which later went unnoticed by a pharmacist or nurse.
  • Recording on the Wrong Patient Chart: Another EMR documentation mistake is entering orders in the wrong patient’s chart. Though uncommon, this mistake usually occurs when patients share the same name. It poses a major patient safety hazard. For instance, if a medication order is transcribed onto the wrong patient’s chart it will result in the medication being administered to that patient. NSO recommends assigning a different nurse to each patient when there are two or more patients with the same name. The patient’s wrist band should be checked before giving medications. Organizations should also implement a system of identifying patients’ names and medication records.
  • Misplaced Documentation: According to AHIMA misplaced documentation concerns range from “data entered into the wrong field in an EHR to scrounging for missing pieces in a hybrid health record environment, misplaced information”. Common issues include misplaced progress notes, different providers using different terminology to explain the same condition, etc.
  • Not Completing the Medical Record within the Specified Time: Each patient’s condition and history of care should be recorded in a timely manner. There are specific time requirements for completion of each element in the medical record:
    • History and Physical – completed and signed within 24 hours of admission
    • Post-op note – written immediately after surgery
    • Operative Note – dictated and signed within 24 hours of operation/procedure
    • Medical Record – should be completed within 7 days of discharge or outpatient visit

Strong documentation practices improve team communication and continuity of care. EHR documentation can be significantly improved through the use of medical transcription services. Skilled medical transcriptionists can ensure timely and accurate documentation to convey clinical information about patients’ diagnoses, treatment, and outcomes.