Medical Record Documentation – Ways to Ensure Accuracy

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Accurate documentation of medical records is
crucial as it impacts the safety of the patient,
appropriateness of care provided as well as
further care planning. Healthcare providers can
consider partnering with a reliable medical
transcription services provider for better
documentation.
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• Incomplete or missing data
• Unnecessary blank space in forms within the
  medical
• records
• Misplaced medical documentation
• Not entering new medical conditions or symptoms
• Misuse of copy and paste function in the EHR

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Most Common Medical Errors in a Healthcare
Document

• Errors due to illegible physicians handwriting
  or
• misunderstood dictation
• Entry in wrong charts of files
• Duplication of medical records
• Failure to document omitted treatments/medications

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Tips to Avoid Medical Errors

• Eliminate shortcuts like copy paste in EMRs
• Avoid using vague terms
• Avoid unnecessary comments
• Use the patients own words and gestures as far
  as possible
• Take sincere effort to correct mistakes
• Avoid delay in documentation

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• Ensure clear and legible handwriting
• Ensure to enter data in the correct patient
  records
• Dont insert new notes or delete an entry
• Avoid documenting incomplete treatments and
  medications
• Review notes transcribed by a third party for
  transcription
• errors
• Entries must be signed before they are added to
  the patients
• record

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• Conducting chart audits regularly helps to
  monitor how
• physicians are complying with accurate
  documentation
• standards
• Assigning a staff member to ensure that
  physicians are
• signing orders in patients medical records in
  a timely
• manner
• Investing in good Health IT solutions would
  enable
• improved patient care and help ensure complete
  and
• comprehensive medical documentation

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