Given the fact that providers have to maintain patient medical records adequately, especially to facilitate medical record review, there are a few snares that they should avoid. Here are some considerations.
- Unreadable records: Make sure that the medical records, if handwritten, are legible and the information entered is accurate. A reviewer should find it easy to read and understand the details entered in the record.
- Not complying with standard requirements: Ensure that all items required by the provider’s state regulations are there in the medical record. If it is not there, the provider is likely to face disciplinary action and claims of negligence for faulty record keeping.
- Overuse of abbreviations: This is considered a bad practice and reflects the hurried or uncongenial attitude of the provider. It will prove particularly bad in malpractice suits.
- Derogatory remarks about the patient: If such remarks are there in the medical record, it will only serve to defame the provider. Moreover, it is unprofessional to use such language. Medical records are to contain only relevant, accurate information that is necessary with regard to the patient’s care.
- Mistakes in the records: Errors in the records should be avoided, and if an error is made, it should be corrected through the strikeout method. The date of correction must be clearly mentioned. Too many mistakes in a medical record will create the impression that the provider is negligent or careless.
- Failing to include pertinent information: This is a grave mistake and may prove costly in the long run, if there is a malpractice or injury case. Tests, conversations with the patients, consultation with another provider, instructions given, precautions taken should all be clearly mentioned in the records.