Medical malpractice always makes the headlines. While we have all read stories about surgeries gone wrong or medical professionals acting fraudulently, there are not typically major stories about doctors and nurses making mistakes with paperwork. Yet, this does not mean that these mistakes are not major or impactful. In fact, paperwork errors can cost doctors and nurses their medical licenses in some instances. This is because, depending on the nature of the paperwork error, a patient can be harmed or even die when a medical professional relies on the paperwork error. This article describes some of the most common medical documentation errors.
Why Do Paperwork Errors Happen?
Before we get into the most common medical documentation errors, it is critical to understand why these errors happen so that the mistake can be avoided. Many times, when there is a paperwork error, it is due to rushing. Doctors and nurses have incredibly busy shifts. They are also often managing multiple patients at once. These medical professionals may have also just worked a long shift. All of these factors can combine to cause someone to make an honest mistake. When someone asks for a signature or some information, a doctor or nurse may accidentally provide the wrong information simply from fatigue or distraction. Unfortunately, no matter what the cause is, the result can be devastating for the patient.
What is a Medical Documentation Error?
Medical documentation errors, or paperwork errors, happen in medical records. A medical record has all of the information about a patient’s health history, including the medications they take, any allergies, test results, and diagnoses. Those records can be viewed by all of the healthcare providers who are giving care to the patient. Medical professionals rely on information in the medical record to make decisions about what sort of care to give to the patient.
A medical documentation error is a mistake in your medical record. There are several different examples of medical documentation errors. Here are some of the most common ones:
- Not Documenting
One of the most common paperwork errors has less to do with a mistake within the paperwork itself and more to do with the process of doing the paperwork: not documenting. Filling out medical reports is a crucial part of a doctor’s job, but it can be very tedious. While a doctor may be very attentive to the patient, she might fail to document what she is seeing. This can harm the patient down the road because the doctor–or someone else involved in the patient’s care–will not see relevant information about the patient’s history and act incorrectly.
- Using the Wrong Abbreviations
Using abbreviations is highly accepted and prevalent in the medical field. However, their use can cause confusion that is significant enough to cause harm to patients. This is especially the case with abbreviations for medications. Errors in medication are one of the most common causes of preventable morbidity and mortality in a healthcare setting.
- Not Documenting Omitted Medications or Treatments
Perhaps you start a patient on a particular medication or treatment plan and then shift course. It is up to the medical professional to document any change. If not, another medical professional will rely on the old information and continue the old treatment plan. This could result in a patient receiving treatment that is harmful to them or even receiving double the medication.
- Messy Handwriting
The stereotype is true: doctors and other medical professionals can have some pretty horrific handwriting. While electronic records have typically eliminated the errors stemming from misinterpretation of messy handwriting, it does still occasionally happen. Sometimes, messy handwriting can lead to a decision that costs a patient his life.
- Transcription Error
A transcription error is an example of a data entry error. This is where the incorrect information is documented, or there is an error inputting the correct information. For instance, the number associated with a patient, procedure, or medication may be long. If a medical professional puts in the wrong number or transposes a number, this can cause an error. Another example is if a doctor writes “hyper” instead of “hypo.” It does not require much imagination to think about what would happen if a hypertensive patient did not receive their blood pressure medication because someone else thought that they were hypotensive when reading the notes.
Preventing Documentation Errors
The best-intentioned medical professional can make mistakes with documentation. Here are some top tips to avoid medical record errors.
- Avoid writing things by hand.
This is not to say that mistakes cannot happen with electronic charting. However, doing things electronically avoids any errors that would arise from messy handwriting.
- Document things on time and when focused.
Many documentation issues arise when a doctor is trying to remember something after the fact or, during the moment, is swamped. Though healthcare settings are notoriously rushed, taking time to properly document what you have seen is imperative to preventing medical report errors. On the flip side, do not document medications and treatments before they are completed or administered. While it is tempting to get ahead of things, if there is a delay or change of plans, then incorrect information has been included in the chart.
- Avoid copy and paste.
Copy and paste is such a time-saver, especially when so much of the information coming from a patient from one time to another time can be similar. Resist the temptation. You may mistakenly include inaccurate or outdated information
- Clearly correct errors.
Mistakes happen to everyone. If you make an error in the chart, correct it immediately. Also, make clear what you are correcting. If using electronic records, your institution will have a protocol for how to correct errors. Do take care to ensure that readers understand what you are correcting.
Facing an Uncertain Future After a Paperwork Error?
Paperwork errors should not be taken lightly by doctors or nurses. They can jeopardize your licenses. Fortunately, an experienced medical license defense attorney can help guide you through this challenging time when you are facing a hearing with a medical board. Reach out to a seasoned medical license defense attorney who has had great success for clients to protect your medical license. Contact our office today.