Incomplete and erroneous medical records are a grave danger for patients, and they also put the clinician at the risk of medical malpractice. Serious errors and missing information are frequently discovered during a medical records review process. Even with the electronic chart, mistakes are often made by physicians, nurses and other clinicians when making entries. According to southfloridareporter.com, a study conducted by Johns Hopkins found that medical errors have risen so high as to become the third top cause of death in the United States. Medical death data of more than eight years revealed that ten percent of all deaths in the United States, or over 250,000 deaths were caused by medical errors.
A medical chart review company performing review of patients’ medical charts may come across the following common errors:
- Incomplete or unreliable medical histories: A patient’s medical history is of great importance. Any serious illnesses, surgeries undergone, medication allergies and sensitivities, current diagnoses and family history must all be clearly documented. When any of these are missing, it could prove dangerous for the patient.
- Missing notes: It is important that all discussions between the doctor and his/her patients are properly and completely documented. The same goes for any conversation with consulting physicians and care providers. Adequate documentation will help avoid gaps in care and resultant confusion. Any recommendations made by consulting specialists must be recorded because it they aren’t recorded the patient would not receive critical care that may have been advised.
- Entries made on the wrong patient’s chart: With a large number of patients visiting a hospital, there is a possibility that one patient might be confused with another. Though inadvertent, this error can have dire consequences. Such mistakes may happen commonly when two patients share the same last name and are on the same unit. This could lead to the wrong medicines being prescribed to the patients and potential malpractice liability.
- Not documenting the discontinuation of a drug or medication: It is important to record that the patient has been scheduled to be taken off a medication. Only then can doctors, nurses and the patients themselves will be aware of this fact. To avoid such an error, nurses must make it a point to cross-check doctors’ orders and medication sheets.
- Not documenting nursing actions: Nurses sometimes fail to record everything they do for the patient on the medical chart. This mainly happens when they are hard-pressed for time. This mistake can be avoided if nurses consider flow sheets that can be inserted in the patient’s medical chart at the end of each shift, says David Griffiths, senior vice president of the Nurses Service Organization (NSO), Hatboro, PA. This can be reviewed and each staff member can use it as a starting point throughout the day and evening.
- Not documenting observations: There is considerable interaction between nurses, nursing aides and hospital patients. Any significant observation must be clearly documented because it could be very important to the patient’s health and wellbeing.
- Documenting only positive findings: This can create problems because both positive and negative findings have an impact on the diagnosis.
- Use of abbreviations: Wide use of abbreviations can create serious issues in both paper and electronic documentation. The same abbreviation can signify different things. For instance, MS can signify multiple sclerosis, morphine sulfate, mental status, or mitral stenosis. Susan Wallace, directory of compliance at Administrative Consultant Service, says that as a shortcut, physicians may document “multi-organ failure” rather than mentioning the specific organs. This can fail to indicate the seriousness of an illness and compromise patient care.
- Transcribing physician’s mistakes blindly: The doctor may have made an inadvertent mistake when writing the quantity of a certain drug to be ordered for a patient. A nurse may have doubts regarding this but may blindly transcribe the mistake. This will result in the wrong dosage of the drug being given to the patient and consequent malpractice risk. So, if a nurse suspects there may be a mistake or some kind of miscommunication as regards the patient’s treatment or prescription information, he/she should cross check and clarify.
Though documentation and paperwork related to patient care may seem tedious and time-consuming, physicians, nurses, and other caregivers must ensure that no mistakes creep into the medical chart. As a medical chart review company, we know that when preparing the medical chart, providers must record all health and drug information; medications that have been stopped; medications that were given; all nursing actions; changes in the patient’s condition; and orders given as regards the patient’s care. To avoid charting mistakes, clinicians must be aware about the documentation errors that could occur when preparing the chart. Careful attention to detail would help providers stay free from medical negligence lawsuits.