Medical Record Documentation – Ways to Ensure Accuracy - PowerPoint PPT Presentation

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Medical Record Documentation – Ways to Ensure Accuracy

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Accurate documentation of medical records is crucial as it impacts the safety of the patient, appropriateness of care provided as well as further care planning. – PowerPoint PPT presentation

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Title: Medical Record Documentation – Ways to Ensure Accuracy


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Accurate documentation of medical records is
crucial as it impacts the safety of the patient,
appropriateness of care provided as well as
further care planning. Healthcare providers can
consider partnering with a reliable medical
transcription services provider for better
documentation.
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  • Incomplete or missing data
  • Unnecessary blank space in forms within the
    medical
  • records
  • Misplaced medical documentation
  • Not entering new medical conditions or symptoms
  • Misuse of copy and paste function in the EHR

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Most Common Medical Errors in a Healthcare
Document
  • Errors due to illegible physicians handwriting
    or
  • misunderstood dictation
  • Entry in wrong charts of files
  • Duplication of medical records
  • Failure to document omitted treatments/medications

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Tips to Avoid Medical Errors
  • Eliminate shortcuts like copy paste in EMRs
  • Avoid using vague terms
  • Avoid unnecessary comments
  • Use the patients own words and gestures as far
    as possible
  • Take sincere effort to correct mistakes
  • Avoid delay in documentation

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  • Ensure clear and legible handwriting
  • Ensure to enter data in the correct patient
    records
  • Dont insert new notes or delete an entry
  • Avoid documenting incomplete treatments and
    medications
  • Review notes transcribed by a third party for
    transcription
  • errors
  • Entries must be signed before they are added to
    the patients
  • record

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  • Conducting chart audits regularly helps to
    monitor how
  • physicians are complying with accurate
    documentation
  • standards
  • Assigning a staff member to ensure that
    physicians are
  • signing orders in patients medical records in
    a timely
  • manner
  • Investing in good Health IT solutions would
    enable
  • improved patient care and help ensure complete
    and
  • comprehensive medical documentation

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