How to Prevent Documentation Errors in Healthcare

The definition of healthcare documentation errors can be a little fuzzy. Many providers think their notes are perfectly fine, only to learn at an audit they've been leaving out key details for years. Perhaps you rely on copy-and-paste a little too much, or maybe you think that you can use acronyms as long as you understand what they mean.

Remember that healthcare documentation serves many purposes. It helps providers track progress and make diagnoses, of course, but it also covers them if someone were to take legal action, helps other providers understand a patient's situation, supports research goals and informs reimbursement decisions. In the eyes of many, if it isn't in the chart, it didn't happen. Accuracy is essential for meeting these potential purposes.

Errors can come from many places, but some common examples of medical record errors include the following:

• Simple typos that change the meaning of a word, such as substituting "hypo-" for "hyper-"
• Transcription errors
• Omissions, like forgetting to log a patient concern or a discussion that happened over the phone
• Inaccurate inclusions, like documenting a discussion of risks that did not occur
• Incorrect medication instructions
• Using abbreviations — which can have multiple meanings — or non-standard terms that can cause confusion
• Making entries into the wrong patient's chart, such as for patients with the same name
• Entering the wrong demographic data, such as an incorrect address and phone number
• Entering the wrong diagnosis
• Vague or subjective language

In some cases, providers need to simply change their wording. Other documentation errors call for more systemic changes, like implementing identify verification procedures or shifting away from dictation-oriented processes.

Consequences of Poor Documentation in Healthcare

When you work with so many notes, it can be easy to see them as a cumbersome administrative task and lose sight of the importance they hold in the healthcare system. Without accurate notes, patients, providers and the general public can face concerns like:

• Negligence and malpractice: Poor notes can result in charges of negligence and malpractice, as they fail to reflect the patient's medical needs.
• Insurance coverage issues: An inaccurate diagnosis or treatment code can cause a patient to be denied necessary coverage.
• Inaccurate treatment decisions: Misdiagnoses, medication interactions or other adverse effects may come from poor documentation practices.
• Poor communication: Documentation issues can impede collaboration between providers, departments and other facilities.
• Unnecessary or inappropriate testing: Incomplete or inaccurate records may lead a doctor to order a duplicate or unnecessary test.
• Inhibited research and population health initiatives: Charting often contributes to medical research, so poor records can hurt those efforts and stifle innovation. They can also make it difficult for organizations to collect accurate population-level data.
• Reduced reimbursements: Insurance companies often turn to documentation to determine the validity of a reimbursement. If your notes aren't suitable, they may deny payment.