5 Common Errors in Medical Documentation (and How to Avoid Them)

5 Common Errors in Medical Documentation

In 2006, when patient Susan Meek went into the hospital, nurses were told to give her leg examinations to reduce the risk of blood clots. But the nurses didn’t record whether they had done the examinations. When a blot clot formed and damaged Meek’s nervous system, the hospital had to pay $1.5 million, all because the medical records didn’t contain enough information.

Medical documentation errors can lead to mistreatment and even death. These errors also cost money. But proper training and attention to detail can prevent some of the most common errors.

Read on to learn about the five most common documentation errors, and how to avoid them.

1. Hiding Errors

If you make a mistake in a written record, don’t erase it, cross it out with a thick marker, cover it with correction fluid, or scribble over it to make it unreadable. Instead, make the correction in a way that preserves the original, such as lightly crossing it out, writing the new information in the next available space, and initialing your change.

If you need to correct an electronic record, create a new record with the correct information, date, and time. Make it clear that the new version is fixing an error in an old version, and make the new version easy to find.

2. Using Copy and Paste

Although it seems like a reasonable shortcut, copying and pasting can lead to errors and unusable files. A simple entry noticing a single detail can get copied and pasted, repeating that detail until it looks like a chronic condition. Copying and pasting can also quickly fill up charts.

Instead, write out a new entry for each occasion. This will reduce the risk of repetition and keep the information up to date.

3. Failing to Record Omitted Treatment 

In addition to documenting treatments, you must also document which treatments and medications were not given. Also list the reason, such as whether the patient declined an offered treatment, or whether the clinic was short-staffed.

4. Inaccuracy

In handwritten records, sloppy or illegible handwriting can lead to errors and medical mistakes. Audio dictation can also lead to errors, such as when a transcriptionist writes “hypo” instead of “hyper.” Even voice typing can lead to mistakes when the software interprets one word for another–read this article to find out why.

Always check to make sure the written record is both legible and accurate. 

5. Confusing Terms and Abbreviations

Even when you’re entering information accurately, you need to make sure all other readers understand the correct information. For instance, medical abbreviations can easily be confused, such as q.i.d. (four times a day) for q.d. (every day). Doctors also sometimes use their own terminology not familiar to other readers.

When possible, avoid abbreviations that might mix up readers. Also, make sure that everyone uses the same medical terminology. 

Develop Medical Documentation Protocols

Once you understand where medical documentation errors creep in, it will become easier to avoid making them. Produce clear and accurate records, make a note of ommissions, and leave errors in place to keep your charts in good shape. This will reduce medical errors and help you give your patients the best care.

If you enjoyed reading this, check out our blog for more interesting articles. 

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About the Author: Amanda Byers

Amanda Byers is a graduate of Columbia, where she played volleyball and annoyed a lot of professors. Now as Zobuz’s entertainment and Lifestyle Editor, she enjoys writing about delicious BBQ, outrageous style trends and all things Buzz worthy.