Diagnostic errors are a persistent problem in healthcare practices. We have seen earlier how diagnostic errors are a top concern in the healthcare industry. The National Academies of Sciences, Engineering and Medicine, recently published a report entitled ‘Improving Diagnosis in Healthcare,’ which explores the ways to curb diagnostic errors in healthcare practices. According to the members of the writing committee, people experience at least one diagnostic error in their lifetime with sometimes serious consequences. The report explores the significance of accurate clinical documentation, the role of nurses and how EHR documentation is helpful. Let’s consider the highlights of this report and see how medical transcription is significant.
The Committee articulated eight goals to curb diagnostic errors in healthcare practices such as:
- Ensure more effective teamwork during the diagnostic process
- Improve healthcare professional education and training in the diagnostic process
- Make sure that health information technologies support patients and healthcare professionals during the diagnostic process
- Develop and employ approaches to detect, learn from and reduce diagnostic errors as well as near misses in clinical practice
- Establish a work system and culture that can support the diagnostic process and enhancements in diagnostic performance
- Develop a reporting environment and medical liability system that support enhanced diagnosis via learning from diagnostic errors and near misses
- Deploy a payment and care delivery environment that supports the diagnostic process
- Provide funding for research on the diagnostic process and diagnostic errors
Role of Clinical Documentation and Nurses
There are four types of information gathering activities in the diagnostic process as per the committee such as taking a clinical history and interview, conducting a physical exam, obtaining a diagnostic testing, and sending referrals or consultations to the patient. Clinical documentation contains the patient’s clinical history and symptoms, physical findings, the results of diagnostic testing, medications and therapeutic procedures. There would be a separate medical chart associated with each facility from which the patient seeks care. When the patients change their source of care, information maintained by the previous clinicians may or may not be incorporated into the record or there would be significant changes. Healthcare facilities should not only remain alert while documenting the information, but also track them carefully.
Nurses play a key role in the diagnostic process as they facilitate communication with the patient by asking about their history, actively listening to a patient who describes his/her reasons for a visit, documenting patients’ symptoms, assessing vital signs, and conveying this information to other team members. They should remain as full and active members during this process to present their observations and conclusions to other team members. Accurate and comprehensive documentation via nursing transcription is vital to avoid diagnostic errors.
Improving EHR Documentation to Prevent Diagnostic Errors
Accurate clinical documentation via electronic medical records can provide the following opportunities to reduce diagnostic errors such as:
- Easy access to information with improved selectivity of information searches
- Provides a space for recording and sharing assessments
- Maintain dynamic patient history
- Maintain problem lists
- Track tests and medications
- Ensure coordination and continuity
- Enables follow-up
- Provides feedbacks and prompts
- Increases efficiency
However, the EHR documentation is still challenging due to limited narrative description and risk of copy and paste errors. Healthcare professionals may copy the information from a patient’s history from one document to another to reduce their time and frequent copy pasting information results in inadvertent errors, which in turn increases diagnostic errors and near misses. EHR transcription or a combined approach of EHR and medical transcription is therefore effective at reducing diagnostic errors. This type of transcription is provided by medical transcription companies that offer the service of trained medical transcriptionists. This enhances the accuracy of diagnostic data. Practices also get to enjoy valuable savings in terms of money, effort and time.