The document highlights nine common medical charting errors that healthcare providers should avoid to prevent serious risks to patients and malpractice claims. It emphasizes the importance of accurate and complete medical records, noting that medical errors are a significant cause of death in the U.S. A medical chart review process can help identify and rectify these errors, ensuring better patient care and reducing legal risks for providers.

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9 Common Medical Charting Errors That
Providers Must Avoid
Medical chart review rectifies incomplete and erroneous medical records that pose
serious risks for both patients and physicians.

2. www.mosmedicalrecordreview.com 918-221-7791
Patient care involves lots of documentation and paperwork, which physicians,
nurses, and other caregivers might find tedious and time-consuming.
However, healthcare providers should take care to ensure that no mistakes
creep into the medical chart as incomplete and erroneous medical records are
a serious danger for patients. Errors in medical records also put the clinician
at the risk of medical malpractice. In fact, according to
southfloridareporter.com, a study conducted by Johns Hopkins found that
medical errors have risen so high as to become the third top cause of death in
the United States. Medical death data of more than 8 years revealed that 10%
of all deaths in the United States, or over 250,000 deaths were caused by
medical errors.
Even with electronic charts, physicians, nurses and other clinicians often
make mistakes while entering information. A medical chart review
company discovers such errors or mistakes while performing review of
patients’ medical charts. Here are the common errors that are discovered
during the medical records review process:
1. Incomplete or unreliable medical histories
2. Missing notes
3. Entries made on the wrong patient’s chart
4. Not documenting the discontinuation of a drug or medication
5. Not documenting nursing actions
6. Not documenting observations
7. Documenting only positive findings
8. Use of abbreviations
9. Transcribing physician’s mistakes blindly

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Clinicians must be aware about documentation errors that could occur when
preparing the medical chart. They must record all health and drug
information, including medications that have been stopped and medications
that were given, all nursing actions, changes in the patient’s condition, and
orders given as regards the patient’s care. Careful attention to detail would
help providers avoid medical negligence lawsuits.
To learn more about medical charting errors, read: Medical Charting Errors
That Providers Must Avoid