Medical Record Documentation – Ways to Ensure Accuracy

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Presentation Description

Accurate documentation of medical records is crucial as it impacts the safety of the patient, appropriateness of care provided as well as further care planning.

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Presentation Transcript

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Documentation Medical Record – Ways to Ensure Accuracy

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Accurate documentation of medical records is crucial as it impacts the safety of the patient, appropriateness of care provided as well as further care planning. Healthcare providers can consider partnering with a reliable medical transcription services provider for better documentation.

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Most Common Medical Errors in a Healthcare Document Incomplete or missing data Unnecessary blank space in forms within the medical records Misplaced medical documentation Not entering new medical conditions or symptoms Misuse of copy and paste function in the EHR

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Most Common Medical Errors in a Healthcare Document Errors due to illegible physician’s handwriting or misunderstood dictation Entry in wrong charts of files Duplication of medical records Failure to document omitted treatments/medications

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Tips to Avoid Medical Errors Eliminate shortcuts like copy paste in EMRs Avoid using vague terms Avoid unnecessary comments Use the patient’s own words and gestures as far as possible Take sincere effort to correct mistakes Avoid delay in documentation

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Ensure clear and legible handwriting Ensure to enter data in the correct patient records Don’t insert new notes or delete an entry Avoid documenting incomplete treatments and medications Review notes transcribed by a third party for transcription errors Entries must be signed before they are added to the patient’s record

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How to Ensure On-time Completion of Medical Documentation Conducting chart audits regularly helps to monitor how physicians are complying with accurate documentation standards Assigning a staff member to ensure that physicians are signing orders in patients’ medical records in a timely manner Investing in good Health IT solutions would enable improved patient care and help ensure complete and comprehensive medical documentation

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Outsourcing medical transcription to an experienced firm is a great option for physicians and healthcare organizations to meet their documentation tasks on-time.

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Headquarters: 8596 E. 101st Street, Suite H Tulsa, OK 74133 Phone: 918-221-7809 Contact us: Thank You…

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