Dangers in Medical Documentation
The many pitfalls of electronic documentation!
• Slip-shoddy documentation can lead to
• The shocking news of patients dying due to
documentation errors, is hitting the headlines
• Patients blame physicians, medical practitioners
blame poorly designed EHR systems, and EMR
vendors blame the physicians’ reluctance to
Too, much of a good thing…
• Extensive medical documentation can help providers
survive audit scares.
• But overload of medical information is scaring the
daylights out of physicians.
• Some notes are stored chronologically, it can take
forever and a day to, locate pertinent information.
• Most physicians follow the unhealthy trend of avoiding
nursing notes altogether to save time.
• Most medical practices miss out on pertinent information
while making the transition from paper records to
• Paper records, that contain important information, risk
being sent to the shredding machine.
• Thanks to a huge amount of omitted and incorrect
information, most physicians don’t trust their electronic
medical records and are inherently suspicious of the
veracity of the records.
The pitfalls of carrying forward information…
• Medical practices have faced a lot of flak for sloppy
• Misrepresentation of information and clinical plagiarism
are on the rise due to the reckless carrying forward of
information, and sloppiness.
• Assuming a medical assistant sees a patient, fills in
information and leaves.
• The supervising physician walks in, makes a few
additions to the chart and signs it.
• It inadvertently omits the fact that a medical assistant
• Which tantamounts to fraud in the eyes of the insurer as
it is not clearly documented, who provided the service.
• There are several medical legal problems if physicians
don’t exercise enough caution while documenting.
A better understanding!
• Understanding EHRs.
• Instead of, hoping for EMRs to do everything but make
• Physicians should take some time to understand their
systems, and educate themselves of the challenges and
opportunities EMRs provide.
• Customizing EMRs.
For more details