Skip to main content

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.


Visit: Avontix

Comments

Popular posts from this blog

Rules and Regulations that Govern Healthcare Documentation -Avontix

Picture courtesy: Google Images Healthcare documentation as the name suggests deals with the documentation of healthcare procedures and treatments provided to a patient. As a way to minimize the workload of physicians in documenting their processes in providing healthcare to patients, healthcare documentation plays a critical role in the healthcare industry and gives the physicians much-needed extra time to spend on looking at a more number patients. For the people in healthcare documentation jobs, it is not just sufficient to master the English language skills and medical terminology to be able to do their work efficiently. There are certain points related to the federal rules and regulations that are to be taken care of while transcribing the data accurately within the set time limits. Professional healthcare documentation specialists are expected to be aware of these legal requirements and act accordingly. Confidentiality of patient information: Medical details of a...

Accurate Healthcare Documentation – Key to Improved Revenues

According to the leading health information management professionals, accuracy in healthcaredocumentation and allied services is critical to the generation of revenues to the healthcare facilities. The reasoning given by them is that accurate healthcare documentation fosters the productivity of physicians which leads to increased revenues for the organization. The measures taken by healthcare documentationcompanies for accuracy in transcription should be followed right from the beginning. A template kind of thing should be given to the physicians so as to generate a complete patient chart. Following this method gives great results as the medical transcriptionists will be able to provide complete transcription reports with high-levels of accuracy when they have the full-fledged patient chart. The transcription reports that are generated quickly and accurately pave the way to the faster medical coding of procedures and processes and then the medical billers also have their inpu...

Good Listening Skills Lead to Effective Communication - Avontix

Picture courtesy: toolshero.com T o engage in effective communication, one needs to listen properly and respond. We all know there’s a difference between hearing and listening. When a sound is sensed by the ears, hearing happens; this doesn’t require any special efforts. However, listening happens only when we consciously put efforts to understand the meaning of the words.This requires concentration on what others are saying. Listening by itself requires efforts, so one can understand that listening well requires much more efforts and concentration. To be able to mingle with others easily and actively participate in conversations, it is important that we listen well. Many people wrongly assume that if they are not talking much and letting others do the talking, they are good listeners. What happens in such cases is that they might be hearing to what others say rather than listening well. Listening is an art in itself that needs the practice to perfect. Here are some pointers...