Why Proper Medical Charting is Crucial for Healthcare Providers

Why Proper Medical Charting is Crucial for Healthcare Providers

Medical charting errors cause injuries and death.  That leads to lawsuits for healthcare providers as well as bad press.  Although there are websites that make a joke out of bad medical charting, it’s no laughing matter to the lives these errors affect.  Medical malpractice lawsuits due to medical error are on the rise.  In fact, medical errors are now the third leading cause of death in the United States following heart disease and cancer.

Five of the most common errors made in medical charting include:

  1. Insufficient notations. When a doctor doesn’t use a handheld record during or following a visit with a patient, his or her notes may lack important details that were discovered or discussed.  To avoid this problem, any discussion about care, treatment, testing, and preventative measures should be well documented in the patient’s chart.  This is not only for the doctor to refer to but other medical professionals in the event the patient is seen or hospitalized somewhere other than their chosen healthcare provider.
  1. Inadequate family history information. It’s hard to treat a patient when you know little about their past drug use, medical history, allergies, and family history.  A thorough interview pertaining to this information prevents illnesses by reducing the number of adverse and allergic drug reactions and hereditary conditions.  Something as simple as a person’s family history could save their life by alerting medical professionals to possible conditions and diseases a man, woman or child might have.
  1. Blank fields. It doesn’t matter if the question wasn’t answered, something should be written in the blank spaces provided.  This clears up any questions a doctor might have about known drug allergies, conditions or disease.  It’s best to chart that there are no known conditions than to put nothing at all in a space.  It protects both the patient and the doctor especially if the records are handled by more than one party.
  1. Indecipherable handwriting. There’s a running joke about how doctors have the worst handwriting in the world.  It’s not the least bit funny, however, when a lawsuit ensues because of sloppy scribe.  An ‘a’ takes on different context when it looks like an ‘o’.  Other medical professionals should not be left to decipher handwriting when a person’s life, health, and well-being are at risk.
  1. Problems with medications. If prescriptions and refills aren’t properly documented, a patient may overdose on the drugs or suffer from adverse drug reactions because too many medications are taken at the same time.  Just like pill bottles are labeled with detailed information, medical charts should be, too.

To avoid patient harm and lawsuit, healthcare providers must emphasize the importance of accurate and frequent medical charting.  By providing medical staff with the training needed to chart well, hospitals, health clinics, and nursing home facilities prevent costly and unnecessary mistakes.  Patient satisfaction increases because they know they’re in good hands with medical professionals who go the extra mile to make legible and detailed notations in the man, woman or child’s medical charts.

 

 

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