First Products Good Medical Charting vs Bad

Medical errors are a serious problem across the healthcare landscape.

In fact, according to researchers at Johns Hopkins, they now rank as the third-leading cause of death in the United States. Their analysis of eight years worth of medical data suggested that 10% of all deaths examined – more than 250,000 – were the result of a medical error.

Few such mistakes are as dangerous – or as potentially deadly – as incomplete or erroneous medical charts and records.

                               Mov-it Elite Chart Rack: Series I

The Financial Benefits of Sustainable BuildWhat Causes Medical Charting Mistakes?

Medical charting and record errors can occur for many reasons. 

Very often, the problem originates from a health organization’s failure to define exactly what  constitutes poor charting practices. In general, shoddy documentation is defined as documentation that lacks clarity, specificity, or completeness. However, this can be in the eye of the beholder and may very well depend on who is using a specific medical chart.

For example, physicians would likely define poor charting as documentation that impairs patient evaluation and/or treatment, while a medical coder would find fault with any documentation that lacks the sufficient specificity to assign accurate diagnosis and procedure codes.

Regardless of how poor documentation is defined, there are a number of practices and circumstances that can contribute to medical charting mistakes and erroneous documentation. 

Insufficient provider education is probably at the top of the list. While physicians tend to document a lot of information, many aren’t familiar with the specific information that needs to be included for coding purposes. As a result, they don’t use the terms needed to provide the highest level of specificity. 

Time – or specifically, the lack of it – can also be a factor. Since patient well-being is always a provider’s first obligation, documentation becomes a secondary priority.

And while EHR technology has reduced charting errors that result from illegible handwriting,  copying and pasting within medical records has emerged as a significant concern. Not only does this sloppy practice  cause a patient’s electronic  record to become bloated with duplicative information, but it can impair original thinking among clinicians.

                                     Mov-it Elite Chart Rack: Series II

Common Medical Charting Errors

The most common medical charting errors include:

Incomplete Medical History and Missing Notes

A patient’s medical history is an incredibly important component of any medical chart. Failing to document a serious illness, past surgery, medication allergy, family history, and current diagnoses could result in prescribing and treatment errors that place a patient’s well-being in serious danger.

To avoid confusion and gaps in care,  it’s also essential that medical charts properly and completely document:

• All discussions between a doctor and their patients.
• Conversation with consulting physicians and care providers.
• Any  recommendations made by consulting specialists.
• Any significant observations.

Information Entered on the Wrong Patient’s Chart 

It’s surprisingly easy to confuse one patient’s chart with another, especially in a large hospital where multiple patients might share similar – or even the same – names. This could lead to the wrong medicines being prescribed and potential malpractice liability.

Failing to Document the Discontinuation of a Drug or Medication

Failing to remove a discontinued drug or medication from a patient’s chart is every bit as dangerous as failing to add one that’s been newly prescribed. By making a point to cross-check physician's orders with medication sheets, nurses can prevent this error.

Failing to Document Nursing Actions

Nurses are incredibly busy and sometimes fail to note everything they do for patients during their shift. Inserting a flow sheet in a patient's medical chart template at the end of a shift can help prevent this mistake. The flow sheets can be reviewed by other staff members and used as a starting point throughout their own shifts.

Using of Abbreviations

Both physicians and nurses may be tempted to use abbreviations when they’re pressed for time, but abbreviations create serious issues in both paper and electronic documentation. The same abbreviation can signify different things. For instance, MS can signify multiple sclerosis, morphine sulfate, mental status, or mitral stenosis. The resulting confusion can potentially compromise patient care

Transcribing Physician Mistakes

Doctors are human and can make inadvertent mistakes when writing the quantity of a certain drug to be ordered for a patient. If a nurse has doubts, but blindly transcribes the mistake, the patient could be at risk from receiving an incorrect dosage. If a  mistake or miscommunication is suspected, nurses  should cross check and clarify.

First Products Medical Charting Solutions

First Products believe that every caregiver deserves perfect fit solutions that meet  their  many ergonomic, workflow, security,  and safety needs. 

We’ve been serving the healthcare industry since 1945. Today, First Products offers more than 10,000 patient charting and record keeping products in over 6 countries worldwide.

We’re confident we can meet your needs. Let's build your medical charting solution together.

To Learn More, Please Contact First Products Today at 800.854.8304.