Clinical documentation errors occur for a number of reasons, and can put both your organization and your patients at risk. Unfortunately, the traditional approach to creating reports is riddled with pitfalls that can lead to increased clinical documentation errors. Some of the most common types include:
Clinical Documentation Errors Occurring During Transfer or Medical Transcription:
Every time information is translated from one format to another or moved manually from one system to another, there’s a fresh opportunity for error. Some of the points along the traditional process where errors most commonly occur include during transcription, during entry of handwritten notes into an electronic system and during manual transfer from one system to another. Eliminating transfer and translation from the medical reporting process eliminates many of the opportunities for clinical documentation errors.
Clinical Documentation Errors of Omission:
In a study of cancer-related pathology reports, the College of American Pathologists found that free narration of reports resulting in variations that made it difficult to use those reports, and attributed the variation mainly “to dictated free-text that contained transcription errors, insufficient and sometimes omitted clinical data.” It’s easy to understand how free narration would result in insufficient or omitted data; there’s no standard format to follow and, as the clinician dictates, he or she cannot easily glance back to ensure that all important information has been included. Template reporting can eliminate such omissions by prompting clinicians to provide specific data and even forcing completion of critical fields.
Clinical Documentation Errors Made by Clinicians:
Your clinicians are busy people, and that sometimes means delays in report completion. That’s understandable, but it also increases the chances that information will slip their minds or cases will become confused during the period between the procedure and completion of the report. Even the most scrupulous of professionals is less well-prepared to complete a report on a procedure three weeks after the fact—and after numerous intervening procedures—than he would have been shortly after providing treatment. Synoptic reporting software, which makes it quick and easy for a clinician to complete a report, minimizes the risk of physician error by encouraging prompt report completion while details are fresh in the clinician’s mind.
Avoiding Clinical Documentation Errors:
The long-standing approach to medical record keeping, which often involves multiple steps and multiple people, opens the door to a wide range of errors. Each time that a clinician dictates a report with no template or checklist, you face the risk that she will leave out pertinent information. And, the more time passes between the procedure and the reporting, the more likely it is that details will be forgotten or misremembered.
Every time that tape passes to a transcriptionist, there’s a possibility that she will mishear or make a typographical error. A data entry clerk transferring the clinician’s handwritten notes into your digital system may not be able to read the physician’s handwriting, or may simply skip a line or mistype.
Synoptic reporting solves all of these problems by providing physicians with a template that ensures nothing is left out, encourages timely reporting and eliminates the need for translation and transfer by transcriptionists and data entry personnel.
What other types of clinical documentation errors have you encountered? Let me know in the comments.
Photo credit: Michael Mandiberg