The process of capturing patient record has always been a big challenge for healthcare providers. It forms the premise for patient care and reimbursements. It is one process prone to multiple mistakes, each of which can have significant impact on profits and efficiency. In this blog we discuss about the common clinical documentation errors and ways to ensure they do not happen.
Mistakes Made in Haste
Mistakes in haste happen mostly with hospitals and physicians who do not depend on EHR to document patient records. Some physicians still rely on coders to make entries either through dictations or through scribbled notes. This opens up a plethora of possibilities to happen. Some such possibilities include, dictating into the wrong patient’s chart, hearing the wrong code, interpreting abbreviations wrongly (MS can refer to morphine sulfate, multiple sclerosis), coder entering without checking codes, not being specific such as stating multiple organ failure instead of naming the specific error and so on.
Incomplete/Missing Documentation:
This is a common documentation error found in medical charts. Many providers commit the mistake of using ambiguous terminology. This makes the interpretation unclear. Sometimes providers unwittingly miss out on providing information in the medical chart. Missing health information leaves the door ajar for presumptions. This can negatively impact both patient care and physician reimbursement. In some cases, missing documentation can lead insurance carriers and Medicare auditors to the provider door steps seeking to look into the right documents.
Misplaced Documents:
Yet another common documentation mistake is misplaced documents. One such example is procedure notes ending up in the progress note section. It happens when there is too much manual involvement. It may also happen when physicians create their own templates instead of relying on EHR templates. Such errors mostly happen in facilities that use a hybrid record model, with both electronic and paper records. This type of errors can lead to serious issues as physicians and nurses are forced to work with incomplete information.
Copy Paste Issues:
This happens mostly with EHRs. EHRs allow users to reuse parts of the narrative in the health record. This is mostly done by copy pasting. During the process it is possible to copy paste the wrong portion of the narrative. Incorrect copy-paste can cause things to go horribly wrong. It can lead to patient harm as it makes it hard to understand the resolution of an ailment. And the worst is that it could alert auditors who are out to spot fraud and lead them to your doorsteps. An erroneous copy-paste can lead to the addition of more pages to a patient’s health record. This will slow down medical processes including medical record review and may even lead to wrong conclusions.
| Did You Know Fall Outs of Documentation Errors -Care was inadequate or incomplete -Non-compliance with regulatory requirements -Highlights poor clinical care -Supports medical malpractice allegations -Supports allegations of fraud -Loss of revenue/reimbursement -Revoke physician/practice license |
Technology is Important, But Not Most Important
Technology has simplified the way medical documentation is done today. Today it depends a lot on smart phone apps, digital dictation, and cloud-based platforms. The efficiency brought in by these tools have made documentation a lot easier and more streamlined. However, the efficiency comes with its own set of drawbacks. For instance, it requires physicians to edit on the front end. This again opens it up to errors. Even physicians find it irksome because it takes valuable time away from patient care. Also, not all of the technologies have checks in place to stop errors from creeping in. Therefore, chances of misdiagnoses, delayed diagnoses or medication errors are always there. Therefore, to eliminate documentation problems completely, it is more important to have a proper culture for documentation.
Pre-requisites for Embracing Documentation Technology
Improve Clinician Environment.
Your clinicians must be comfortable with what they handle. So, knowing what your clinicians and staff prefer to capture documentation c is more important than what you would prefer. Some may seek cutting-edge technology while others may want familiar equipment. The easy way out is to provide staff with a number of options. This will not only ensure better acceptability but also quality documentation. The other advantage is it will help in maintaining equipment, and sustaining a HIPAA-compliant work process
Outline Procedures and Policies.
Always establish correct guidelines for your staff and physician. This will help them meet highest standards consistently. The guidelines must be specific to your practice and processes. It always pays to give a personal approach to workflows by involving all stakeholders in developing the guidelines. This helps in developing a sense of involvement in setting up and following the documentation process. Such an approach can be of immense help to all types of healthcare providers, particularly practices that specialize in a particular field of medicine.
Build a Proper Transcription Team.
Always have the best team for all your documentation needs. The team must consist of experienced and specialized documentation professionals. Such professionals, always understand the nuances of documentation. They are conditioned to follow best industry practices and can deliver the best quality with ease.
Stay Focussed on Specialty
Those who plan to outsource medical documentation, need to match their transcription provider to practice expertise. Settle for vendors who know your practice inside-out. Such providers can leverage their knowledge and exposure to help you achieve perfection in documentation.
Conduct Quality Assurance.
Most organizations develop guidelines and forget to review it at regular intervals. This affects the quality of medical documentation, which in turn affects revenue cycle management. It’s important to review the established documentation process time and again. This will help you elicit staff opinion, get critical feedback and test to ensure high quality output. All these together bring about continuous process improvement.
Conclusion
High quality medical documentation is a must for increasing reimbursement and improving quality of care. To ensure this, healthcare providers must go all out to embrace the right technology and balance it with the right practices. An easy way out is to outsource their requirements to their-party service providers. This will not only help them keep their rcm healthcare services efficient, but also meet the challenge of rising costs.
Who We Are and What Makes Us an Expert?
This article is written by MedBilling Expert, an expert back-office support services for revenue cycle management. One of the rcm process we specialize is medical transcription and documentation. We bank on experienced professionals and the best technologies to deliver accurate medical documentation services to our clients. If you are looking for the best clinical documentation solution, get in touch with us now.
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