9 Common Medical Charting Errors That Providers Must Avoid

9 Common Medical Charting Errors That Providers Must Avoid

Medical chart review rectifies incomplete and erroneous medical records that pose serious risks for both patients and physicians.

www.mosmedicalrecordreview.com

918-221-7791

Patient care involves lots of documentation and paperwork, which physicians, nurses, and other caregivers might find tedious and time-consuming.

However, healthcare providers should take care to ensure that no mistakes creep into the medical chart as incomplete and erroneous medical records are a serious danger for patients. Errors in medical records also put the clinician at

the

risk

of

medical

malpractice.

In

fact,

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 8 years revealed that 10% of all deaths in the United States, or over 250,000 deaths were caused by medical errors.

Even with electronic charts, physicians, nurses and other clinicians often make mistakes while entering information. A medical chart review company discovers such errors or mistakes while performing review of patients’ medical charts. Here are the common errors that are discovered during the medical records review process: 1. Incomplete or unreliable medical histories 2. Missing notes 3. Entries made on the wrong patient’s chart 4. Not documenting the discontinuation of a drug or medication 5. Not documenting nursing actions 6. Not documenting observations 7. Documenting only positive findings 8. Use of abbreviations 9. Transcribing physician’s mistakes blindly

www.mosmedicalrecordreview.com

918-221-7791

Clinicians must be aware about documentation errors that could occur when preparing the medical chart. They must record all health and drug information, including medications that have been stopped and medications that were given, all nursing actions, changes in the patient’s condition, and orders given as regards the patient’s care. Careful attention to detail would help providers avoid medical negligence lawsuits.

To learn more about medical charting errors, read: Medical Charting Errors That Providers Must Avoid

www.mosmedicalrecordreview.com

918-221-7791