Illegible, poorly written, and incomplete medical documentation is an all-too-common problem in healthcare. Below, we discuss ways healthcare professionals and clinics can prevent poor medical documentation and ensure everyone is on the same page.
Avoid Copying & Pasting
One of the most common culprits for mistakes in medical documentation is the dreaded copy-and-paste function for the electronic health record (EHR). Anyone who has used a computer is familiar with its function and its convenience, especially when transferring large amounts of data from one document to another.
However, the copy-and-paste function is a breeding ground for mistakes, as you can easily repeat errors onto multiple documents, making it harder to track an illness’s progression. Repeated copy-and-pasting can also add more pages to documentation than needed, which makes them harder to read and understand.
Use Abbreviations & Symbols Sparingly
Another way to prevent poor medical documentation is to use as few abbreviations and symbols as possible. Medical documentation is often rife with shorthand, abbreviations, and symbols—which can be convenient. However, it can also lead to confusion and assumptions.
While most medical professionals within the same department may see and understand what these abbreviations mean, it’s easy for others to get confused and assume it means something else, which can cause many issues.
Write as Clearly as Possible
It’s the simplest and most obvious advice, but it’s still worth mentioning: always be as clear as possible in your medical documentation. Clear writing applies to the legibility of one’s handwriting and the documentation’s content.
Clarity and precision are critical aspects of medical documentation, but many overlook them for more time-saving writing methods. After filling out your documentation, ask yourself if the paperwork is clear, concise, complete, and legible.
Document Future Plans
One aspect of medical documentation many healthcare professionals overlook is who may be reading their notes and documentation in the future. If a facility must transfer their patient to another facility, the professionals the patient comes in contact with, such as specialists and social workers, may need to consult the documentation to appropriately coordinate their care.
It’s helpful for all involved if healthcare professionals include the patient’s care plans in their documentation. For example, note the date of a follow-up appointment and provide a rough timeline for when treatment can resume. These simple additions can reduce confusion and misunderstanding for those reading the documentation in the future.
Poor medical documentation is a frequent cause of medical malpractice claims against all kinds of healthcare professionals, from physicians to chiropractors and more. Therefore, malpractice insurance is critical for every healthcare professional.
If you’re a chiropractor looking for a chiropractic malpractice insurance quote, Baxter & Associates can help. Contact our staff today so we can help you find a malpractice policy that suits your needs and budget.