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Documentation Errors That You Should Not Overlook -Avontix

        
                        

It is being noticed that documentation errors in medical records that even result in deaths are on the rise. According to studies, inaccurate medical documentation is one of the major reasons for patient deaths in the recent times. Per a report, thousands of the Americans are being killed from preventable adverse effects of inaccurate medical documentation. It is important to incorporate best EHR solutions into your medical practice along with some efforts in documentation processes. Let us understand some common documentation mistakes that cost you.

Incomplete medical record: Care should be taken that patient’s every encounter with the healthcare facility should be documented properly with complete information including the patient’s medical history, reasons for the visits, diagnosis, test results, and treatments.

Risk factors: All the health risk factors should be identified and documented appropriately in the medical records. Along with this, the response shown by the patient towards treatment and any changes in the proposed treatment plan should be keyed in timely.

Chief Complaint: The mention of the chief complaint should be there in every medical note and documentation of the history of present illness is also necessary. It is important that this information is properly documented by the physicians.

Review Documentation: Documentation for The Review of Systems ought to be elaborated and in depth as incomplete note won't help.

Approach:  The kind of approach that we have always done it this way will not work. Documenting the criterion behind the medical decision made and detailing the answers for the “why” and “what” of the treatments will help in future medical necessities.

Data duplication: Care should be taken to avoid duplication of data that can prove to be detrimental for both patients and practice.

Empower the staff: Many physicians do not give importance and time to coach their staff on operating with EHR systems. This successively results in improper documentation of medical records. Empowering the staff is the most effective and easiest way towards accurate documentation.


Along with all these steps to eliminate errors in documentation, integrating the best suitable EHR solutions into your healthcare practice is important. Avontix provides the best EHR solutions for ASC.


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