Clinical documentation errors mean trouble for everyone. They can adversely impact patient care, create administrative delay and increased costs and even result in liability for your facility. Unfortunately, the opportunity for error has been built into the creation of medical records for decades. Traditional free-form dictation and transcription opens the door to many clinical documentation errors and omissions. Some of the opportunities for error in this process include:
- Omission of important data due to free, unguided dictation methods;
- Unclear speech on the part of the clinician or poor sound quality making it difficult for transcriptionists to understand;
- Delays between the procedure and dictation impact the clarity of clinician memory of the specifics of the procedure; and
- Transcriptionists unfamiliar with technical terminology, which can be complex and similar.
Removing those opportunities for error may be most powerful step that an organization can take toward reducing mistakes, improving patient care and keeping administrative expenses under control.
How to Reduce Medical Record Errors
Structured synoptic reporting—electronic entry of medical reports into a template-based form–can help eliminate these clinical documentation errors by:
- Guiding the clinician through a series of prompts and questions to ensure that no important information is omitted;
- Enforcing certain fields as mandatory to protect against accidental omission of key data;
- Allowing clinicians to create editable defaults for fields in which data is typically consistent;
- Controlling the type of data that can be entered into a given field, which helps to ensure proper formatting and identify typographical errors;
- Making it quick and easy for clinicians to complete reports promptly, minimizing the likelihood that details will be forgotten or confused with the passage of time;
- Eliminating the need to transfer information from recordings to print, thus removing a step during which translation errors may occur; and
- Eliminating the need for data entry from handwritten notes, which can also lead to translation or typographical errors.
Safeguards against clinical documentation errors when using the traditional free dictation and transcription method can be labor-intensive, costly and imperfect. Making the process as error-free as possible requires careful screening of transcriptionists, review of completed records and a clear process for correction and verification. Even when a clinician or an administrator identifies clinical documentation errors in a review of transcribed records, it means the added expense of the review and corrections, as well as a delay in the availability of the accurate report.
Synoptic reporting streamlines the process, not only preventing against those clinical documentation errors with guided entry and automated checks, but also helping clinicians to complete those reports in a timely manner, while the details of the procedure are still fresh in their minds.
Photo credit: Jenni C