Valid, accurate, complete, trustworthy, and timely electronic medical records improve the utility of clinical documentation, and enhance communication between healthcare providers. One of healthcare’s worst nightmares is wrong information in the medical record. As a medical transcription company in the U.S., we are focused on converting physician dictation to accurate text. However, healthcare providers can make mistakes that compromise the integrity of the medical records and patient safety. Multiple studies have highlighted the seriousness of the problem:

• A John Hopkin’s study suggested that medical errors account for more than 250,000 deaths per year in the U.S.
• According to a poll by the Kaiser Family Foundation, 21 percent of respondents reported that they or a family member noticed an error in their EHR.
• In a survey study of patients published in in 2020, 1 in 5 patients who read a note reported finding a mistake and 40% perceived the mistake as serious.

Even small errors or omissions in a patient’s medical record can result in serious patient injuries and harm as well as have legal consequences for the provider.

Common Medical Charting Errors

Let’s take a look at the common medical charting errors, why they occur, and how to avoid them.

• Incorrect medical history: Wrong medical information in patient records is a common error. While some errors are harmless, others can be worrying or fatal. CNBC references a leading health IT company estimates that about 70 percent of records have wrong information. The report was on a young student who found that her medical record stated that she had two children when she had never been pregnant! Another study published on JAMA Open Network said that a patient who mentioned chest pain, tightness, and palpitations found all these marked as negative in the chart. In other cases, the provider did not document the most important reason for the visit.

   

  The history is the key component of patient assessment and considered the most important part of the patient-physician interaction. Improving patient history taking practices is crucial to obtain the correct information and drive patient collaboration and trust.

• Inaccurate medication instructions: The five “rights” of medication administration are: right patient, right medication, right time, right dose, and right route. Inaccurate documentation of the patient’s symptoms, diagnosis, or treatment can lead to inaccurate medication instructions. Wrong dose, missing doses, and wrong medication are the most commonly reported administration errors.
   

  Drug administration prevention strategies include standardized communication in electronic health records (EHRs), standardized product labeling, and drug information resources to alert “look alike, sound alike” drug names and using the correct expression of numeric doses.

• Documenting orders in the wrong chart: Factors that lead to orders being wrongly documented in the chart include patient misidentification during registration, difficulty in locating the patient’s EHR, existing duplicate medical records, and typos. Patient misidentification or patient ID errors are among the most common errors in health care. A 2018 Pew Charitable Trusts report found that one out of every five patients may not be completely matched to their medical records.

   

  Patient ID errors can lead to patients getting the wrong treatment, which can have grave consequences. The issue can be avoided with the right identification analyses, workflows, and safeguards in place. Healthcare organizations should identify the root causes of patient misidentification, understand the reasons or contributing factors behind noncompliance, and take steps to correct the problem. Experts recommend having a reliable patient identification system throughout the states.

• Use of inappropriate abbreviations: For physicians and nurses, using abbreviations can be a real time-saver during documentation. Abbreviations facilitate quick charting, but providers and their patient are at risk if it’s not done correctly. Chances of misinterpretation are high with medical abbreviations. For instance, if a nurse misinterprets “mg” as “milligram”, when it actually means “microgram”, it can lead to serious problems for the patient. Further, trying to figure out what the correct interpretation can waste precious time.

   

  There are many error-prone abbreviations in healthcare. The ISMP National Medication Errors Reporting Program (ISMP MERP) allows subscribing healthcare institutions to report and track medication errors in a standard format. The program has published a list of abbreviations, symbols, and dose designations that have misinterpreted and involved in harmful or potentially harmful medication errors. Best practice is to avoid unnecessary abbreviations and use only abbreviations you are certain about and avoid those you don’t know.

• Not documenting important information: When a healthcare professional does not document important information about a patient’s condition or treatment, it can have serious consequences, unless the problem is discovered and corrected in a timely manner. For instance, the treatment history should include:
  • Chief complaints
  • History of illness
  • Vital signs
  • Physical examination
  • Surgical history
  • Obstetric history
  • Medical allergies
  • Family history
  • Immunization history
  • Habits include diet, alcohol intake, exercise, drug use/abuse, smoking, etc.
  • Developmental history

   

  Leaving out any of these elements can result in incomplete information in the medical record. Likewise, a physician may forget to document the results of a laboratory test. Incomplete documentation errors in healthcare can affect care. To prevent this issue, the Medicare Claims Processing Manual says “The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”

• Transcription errors: Transcription mistakes can occur with speech recognition (SR) software. Speech recognition may reduce the clinical documentation burden, but one study found an error rate of more than 7% in SR–generated clinical documents. Researchers have found potentially significant error rates in software-transcribed emergency medicine and radiology notes, according to a study published by the Patient Safety Network (PSNet). That’s why manual editing and review of machine-generated documents is essential.

• Careless use of copy-paste: Another charting mistake relates to the use of the EHR system’s copy-paste function. Many physicians find EHR data entry cumbersome and time-consuming, and try to save time by copy-pasting patient information from previous encounters into the current encounter’s notes.

Medical documentation is an essential part of patient. Errors in documentation can lead to leading to patient injury, including delays in treatment, misdiagnosis, and even death. Healthcare providers to be aware of these errors and take steps to avoid them. Partnering with a professional medical transcription company is an ideal way to reduce the risk of documentation mistakes and promote clear, legible, compliant and timely charting to support superior patient care.