Top 4 Documentation Mistakes Physicians Make And Why It’s Dangerous

  • Healthcare Management
  • HCAHPS - medical management
  • August 25, 2021

Proper documentation in healthcare is crucial not only for your patient's health but also audits, insurance claims and malpractice.

Be On The Look Out For Documentation Mistakes

A hospital, specialist clinic, or ambulatory surgery center (ASC) is a time-sensitive place. Doctors and nurses can see hundreds of patients a day, with many patients requiring swift action. Despite the patient’s status, documenting the medical process is a common thread that runs through all hospitals. Unfortunately, documentation mistakes are common and can be costly.

viralmd healthcare marketing Top 4 Documentation Mistakes In Healthcare And How To Change

Common consequences of poor medical documentation

When a patient enters a hospital, doctors, nurses, and other support staff update medical charts. About 1 in 10 hospital visits includes a medication error. In addition, incomplete or inaccurate data can lead to insurance concerns, including reduced reimbursement. Most of all, patients can get the wrong or improper care, leading to life-threatening consequences. Imagine a malpractice suit coming from something as simple as a lack of documentation. There are 4 common mistakes staff should look out for and correct quickly.

1. Incorrect abbreviations

Hospitals have jargon and code to quickly outline a patient’s condition and medical needs. But, in haste, doctors can sometimes use code that’s not standard throughout the hospital. The code may be common in private practice, for example. The wrong abbreviation leads to the wrong diagnosis or treatment from another doctor. There should be approved abbreviations for nurses and physicians that come from the management team.

2. Illegible handwriting

Something as simple as illegible handwriting from a physician or nurse can be costly. Physicians are focused on caring for patients. Moving from patient to patient this quickly leaves little time to write. As a result, a doctor or nurse can place a treatment or condition that looks similar to another. In some cases, the handwriting slows down care if someone else needs to verify the info or reimbursement is necessary. Moving to computerized documentation can reduce the chances of illegible handwriting.

3. Incomplete instructions

Medical charts contain the current status of the patient and instructions for care. Incorrect or incomplete instructions can mean inconsistent treatment before and after the hospital visit. Patients can go through unnecessary tests, which can be painful or even dangerous. There’s also a chance of readmissions and low HCAHPS scores.

4. Not completing documentation

Incomplete documentation affects factors like aftercare and insurance. For example, insurance auditors need accurate documentation to support the claims submitted by the hospital. This lack of info can lead to delayed or incorrect reimbursements. Incomplete documentation could also mean patients have to relay information again or receive unnecessary treatments. Being specific on a patient’s condition means getting buy-in from medical staff at all levels. Encourage the team to be as detailed as possible.

Changing these documentation issues

There are a few steps hospitals can take to decrease the chances of documentation mistakes. At the top of the list, hospitals need a collaborative approach to accurate records with doctors and nursing. Some other effective strategies include:

  • Constant quality checks from a clinical documentation improvement or CDI specialist team
  • Assessments of the current rate of errors in documentation
  • Computerized documentation
  • Providing doctors and nurses more time to complete documents.
  • Providing proper documentation training from inception

Investing time and resources can improve productivity, performance, and the bottom line.

Proper documentation matters

When hospitals have excessive documentation errors or fail to locate mistakes, the results can be dangerous. Patients could receive the wrong care or inadequate care. There could be a loss of revenue or incorrect insurance claims. And in serious cases, a patient’s death can lead to claims of malpractice. There’s so much at stake in a hospital. All hospitals should put resources into educating the team and reducing mistakes.

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