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...

Patient Access and its Link to Increased Revenue -Avontix

Picture courtesy:  patient.info For a health organization to enjoy a good financial position, its revenue cycle management should be efficient enough to bring in timely payments for the claims submitted and collect the amount due from patients. When either the claims submitted are denied or patients are not paying their dues, it results in unpaid collections and bad debts for the healthcare provider.  One of the ways to reduce revenue losses is having smart patient access. By providing smart patient access, healthcare facilities can see reduced claim denials and improve their revenue cycle management performance. To be able to do this, the RCM services professionals have to collect all the necessary information at the registration process itself. Usually, patients feel that all the work related to registration process is time-consuming and unnecessarily delays the diagnosis and treatment procedure. However, hospital registration process is very critical to colle...

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...