Best Practices to Minimize Electronic Health Record Errors

Best Practices to Minimize Electronic Health Record Errors

Providers looking to reduce documentation workload and minimize EHR errors can use EHR-integrated transcription from a medical transcription company.

www.medicaltranscriptionservicecompany.com

Medical Transcription Services United States

918-221-7809

EHR implementation has become mandatory in all health systems in the United States, and choosing the right one is a major challenge. Providers looking to reduce documentation workload can choose to work with a medical transcription company that provides EHR-integrated transcription. Avoiding errors in the medical records is a major concern because even a minor error can affect the health of the patient as well as pose the risk of malpractice lawsuits against the provider. To prevent medical errors stemming from poor quality medical records, healthcare providers should have the best customized EHR system and be HIPAA-compliant.

Many hospitals prefer a combination of EHR and medical transcription to save physicians’ time and obtain quality patient records. Unfortunately, EHRs come with certain pitfalls.

According to The Doctor’s Company, a Napa, California-based insurer of physician and surgeon medical liability, user factors, i.e. how physicians and others use the EHR, contribute to 64% of their EHR-related claims, whereas system factors—such as a system design failure or lack of alert—contributed to 42%. When using the EHR there are some considerations to take into account to ensure good quality medical records. → Be mindful about the use of templates: Physicians must ensure that the templates are individual to each patient and that particular visit. The details entered into the EHR should be accurate for the patient they are seeing. → Typos or typographical mistakes: Typos, misspelled words, and missing words are common concerns with EHR systems and these can cause serious errors in the medical records. Typos in the names of medication or treatment procedures can put the patient at risk. The ideal way to avoid this is by proofreading. → Use of copy and paste function: Copy and paste function is very convenient to input information but it could lead to costly errors and medical malpractice lawsuits. The copy and paste feature is not the problem; the person who is using it is responsible. The medical notes must be updated with each patient visit and it would be different for each individual. The changes should reflect the right time, date, treatment, follow-ups etc. Copy-pasting details of an earlier encounter would result in erratic data. → Ignoring metadata alerts: When opening a file, physicians may see an alert.

These alerts contain life-saving information that doctors sometimes overlook or ignore. If doctors patiently review these alerts, they can see the earlier diagnosis, treatments provided, and other relevant information. The ideal way to handle an alert is to flag the item, correct it and make the proper notations to ensure that the patient’s chart is up to date. Any possibility of data entry error would then stop with the doctor.

www.medicaltranscriptionservicecompany.com

918-221-7809

→ Drop down menu and auto complete feature: Drop down menu and auto complete feature are common in computers but these can create problems if not used correctly. So entering data and clicking on diagnosis codes should be done carefully. When changes are made in the patient’s health status or if the medication list changes, then the auto complete feature should be turned off. → Missing EHR data: Missing data is another major error in EHR systems and it can lead to wrong treatment. This is normally due to faulty software design or malfunction but often the blame comes to the medical practitioner.

Technology has enabled healthcare providers to work more efficiently and smoothly but relying only on technology can be dangerous. The main objective of healthcare providers is to provide quality care and service for their patient community and to ensure this, accurate medical records are essential. The patient record generated must clearly reflect the medical chart in a way that is usable. When read by a third party, it shouldn’t get distorted or seem ambiguous. Providers can provide full attention to their patients and not get bogged down by EHR documentation by outsourcing medical transcription to a dependable medical transcription company. Alternately, they could use a medical scribe in the consulting room to take care of the documentation.

www.medicaltranscriptionservicecompany.com

918-221-7809