Medical Record Documentation: Paint The Clinical Picture with Complete and Accurate Documentation Medical record documentation errors continue to play a significant role in medical malpractice claims. Incomplete and inaccurate documentation can lead to a variety of unintended consequences including delayed diagnosis or misdiagnosis, patient harm, and death, any of which can lead to medical malpractice claims. Documentation errors encompass missing or incorrect information in charts, notes, transcriptions, and other electronic health record (EHR)-related areas. Copy/forward and drop-down menu functions, the ability to easily document on the wrong patient or in the wrong location of a chart, and late entries that may appear concurrent are all documentation issues that can cause patient injuries and/or impact the defense of a lawsuit. Certain aspects of the medical documentation process may invite behaviors that contribute to errors and inappropriate notations, increasing the likelihood of later liability. November 4, 2024 Practice Management, RCMA/CMA, Resources, Risk Management Business Partner, Medical Record Documentation, ProAssurance, RCMA, Resources, Risk Management 0 0 Comment Read More »
