Every institution strives to reduce medical mistakes such as clinical documentation errors, but some have been more successful than others. Medical records processes, formats and even definitions are inconsistent from one organization to the next. A recent Bloomberg piece argued in favor of a national reporting system using uniform definitions and standards for clinical documentation, suggesting that public accounting would give hospitals a greater incentive to institute checklists, communication protocols and other safeguards.
Sources of Clinical Documentation Errors
At present, however, each institution is on its own. Some states mandate reporting of certain types of errors, but generally not the recordkeeping that identifies them. For best practices in avoiding clinical documentation errors, we looked to the National Quality Forum’s Safe Practices for Better Healthcare.
Some of the key areas identified as opportunities for information-related patient care errors included:
- Inability of multiple caregivers to provide the highest quality care when there is not consistent sharing of complete and accurate information;
- Absence of outside records such as emergency room visit reports from paper medical records; and
- The use of non-standard abbreviations and inconsistent prescribing rules, increasing the likelihood of error.
In other words, when complete information is not promptly, clearly and accurately conveyed to all parties, the patient is at risk. Lapses in such clear communication can occur when clinical documentation errors occur, when important data is omitted or when information is simply not transferred to the appropriate providers in a timely manner.
Just a few of the suggested solutions include:
- Developing a thorough understanding of the workflow and care process systems, then considering technology-based reporting solutions to close the information loops;
- Instituting processes to help ensure patient follow-up and testing; and
- Implementing measurement processes to track information hand-off failure rates.
Complete solutions will require coordination of several efforts, such as improved clinical documentation practices; better hand-off execution and tracking; implementation of checklists, training and other standardization efforts and efficient use of technology. However, each step has the potential to improve outcomes. For example, a reduction in clinical documentation errors through technology results in better information passing into the hands of subsequent caregivers, leading to higher-quality follow-up care. Likewise, clear and reliable processes for handing off information to successor providers will empower those clinicians to both follow established care plans and to make better decisions and diagnoses as care evolves.
The best hospitals recognize that improving patient outcomes is a multi-faceted process that requires reliable and complete clinical documentation both for immediate patient care and in order to assess and improve procedures.