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The Burning Platform

Clinical Documentation Errors That Could Put Your Practice at Risk

Electronic Medical RecordsEvery time you visit a new doctor, he or she requires you to recount your medical history for their own records. Innovations in medical IT, such as electronic health records (EHRs), includes software that allows medical facilities to store all your data in one place. Apart from that, these are accessible to all medical providers across states, which take the hassle out of having to repeat the same process every time you visit a new hospital.

Electronic medical records (EMRs), also used by behavioral healthcare providers, are a small scale version of EHRs. They only stay within the health care provider’s office. These are digital versions of charts that contain diagnoses and treatments received by each patient from a practice. Though already made digital, this documentation system is not 100% error-free.

Insufficient Data on Present Illness or Drug Information

It is imperative that clinicians list their patient’s present illness, as well as their medical history, after each visit, as doctors use these to assess and establish what the patient’s diagnosis and needs are. Forgetting to record important details, such as allergies and diseases that may worsen during treatment, will likely end up in a lawsuit. Whether the practice ends up winning or losing the case, it will greatly affect their credibility as a healthcare provider.

Ruling out Negative Findings

Of course, clinicians want a clean record filled with positive findings, but most of the time, these instances are close to impossible. While they give patients personalized treatments, not all of these work after the first time, as there may be complications along the way. These instances need to be recorded so that clinicians can keep track of what works and what does not, as well progress of their patient’s illness, whether positive or not.

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Incomplete Assessments

After each consultation, physicians need to assess their patients in terms of their improvement and if they still need care. Remember the old saying, “If it’s not written, it didn’t happen”? This puts the patient at risk of misdiagnosis or error in prescriptions during their next visit, as the physician will not have any recollection of the patient’s previous visit unless the required information is on file.

New or not, clinicians need training when working with electronic medical records. Knowing the risks involved will surely improve the documentation process and reduce the practice’s risk of audit.

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