Medical charting involves the meticulous recording and management of patient data in healthcare settings. Although it plays a pivotal role in facilitating communication, ensuring seamless care, and meeting legal requirements, it is evident that errors in recordkeeping are prevalent. These inaccuracies can manifest through transcription discrepancies, erroneous diagnostic findings, improper medication guidance, and instances of documentation being placed in the incorrect patient’s file. While outsourced medical transcription services can mitigate many charting mishaps, it is imperative for healthcare organizations to proactively promote a culture that prioritizes impeccable documentation practices.
Study: Poor Charting compromises Health Information Flow
Charting care involves documenting and communicating patient information across multidisciplinary teams. Ensuring effective communication and collaboration among healthcare professionals can be challenging, particularly when different providers work in different locations or use disparate systems.
Researchers have found incomplete or delayed charting can hinder timely and accurate information exchange, potentially impacting patient care. A study published in the journal of the American Medical Informatics Association which investigated nurse communication and documentation in hospital medical-surgical units, revealed many health information management issues. The study showed that these issues could lead to mistakes that harm patients. When many different nurses take care of a patient within a 48-hour hospital stay, it’s important that they share information correctly. The researchers noted that if each nurse documents things differently or does not enter it in the patient’s record, it becomes challenging to understand what’s going on. The study noted that, because of this, physicians who work in different parts of the hospital might not read what the nurses write.
While smooth information flow is a vital component of a patient’s care and outcomes, medical charting involves several challenges.
7 Key Challenges in Medical Charting
Medical charting is typically carried out by nurses as an integral part of their responsibilities in healthcare settings. The American Nurses Association (ANA) emphasizes the role of clear and accurate documentation in safe, quality, evidence-based nursing practice. However, charting presents several challenges:
- 1. Time constraints: Healthcare professionals often face time constraints due to their demanding workloads. Taking the time to document patient care thoroughly and correctly can be time-consuming when they need to attend to multiple patients within limited time frames. This may result in incomplete, delayed or rushed documentation, potentially compromising the quality of patient care.
- 2. Data overload and data entry errors: The potential for data entry errors is a significant concern in healthcare documentation. With vast amounts of patient data to manage, including medical histories, test results, medications, and treatment plans, important details may be overlooked or omitted during charting. Mistakes can lead to incorrect diagnoses, treatments, or medications, posing a threat to patient safety.
- 3. Balancing detail and efficiency: With the large volumes of patient data, charting care requires finding a balance between providing detailed and comprehensive information while maintaining efficiency. Though comprehensive documentation is necessary for accurate diagnosis, treatment, and follow-up, excessive charting can lead to information overload and time-consuming documentation processes. Striking the right balance between detail and efficiency is crucial to ensure effective communication and workflow management.
- 4. Technical issues: While electronic health records (EHRs) allow for effective charting of care, they can also present technical challenges. System glitches, slow response times, and user interface issues may hamper efficient charting and disrupt workflow.
- 5. Insufficient training in EHR use: Structured language helps with quick decision-making and data analysis. However, proper training is necessary to use the EHR’s copy/paste function, form fields, check boxes, etc. It is estimated that between 66% and 90% of physicians frequently use the copy and paste function. But carelessly copying structured data from one note to another without proper checking can affect reliability of documents and put patient safety at risk. A study in Applied Clinical Informatics found that this practice was linked to 2.6% of diagnostic errors, where patients needed extra unplanned care due to missed diagnoses. Another study from the University of California San Francisco Medical Center noted that as much as 80% of information in a typical progress note is copied or brought in by doctors. This can compromise the accuracy of the notes.
- 6. Lack of standardization and interoperability: Inconsistent charting practices and lack of standardization across healthcare systems can impede information sharing and continuity of care. When healthcare professionals use different terminologies or formats for charting, it becomes difficult to understand and interpret patient information accurately. Moreover, interoperability challenges between different EHR systems can hinder seamless data exchange between healthcare providers.
- 7. Complex legal and regulatory requirements: The medical chart as a legal document that may be used for billing, audits, and legal proceedings. It is essential for legal and regulatory compliance when charting care. Healthcare professionals must adhere to specific documentation standards, such as including relevant information, maintaining confidentiality, and following specific coding guidelines. The complexity of these requirements can pose challenges, especially for practitioners who are not knowledgeable about legal and billing aspects.
Addressing these challenges requires a combination of technological advancements, streamlined processes, standardized documentation practices, and adequate training and support for healthcare professionals. Importantly, healthcare professionals need to strike a balance between providing hands-on patient care and documenting that care. That’s where external support for transcription can come in useful. A growing number of healthcare professionals now outsource medical transcription to reduce time on charting and focus on direct patient interaction. Experienced transcriptionists can help them maintain accurate and timely patient records, facilitating seamless data exchange to support decision-making and continuity of care.