Dangers in Medical Documentation

MedicalTranscriptionsService

The many pitfalls of electronic documentation!

• Slip-shoddy documentation can lead to disastrous consequences.

• The shocking news of patients dying due to documentation errors, is hitting the headlines more frequently.

• Patients blame physicians, medical practitioners blame poorly designed EHR systems, and EMR vendors blame the physicians’ reluctance to learn.

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.

Hidden surprises!

• Most medical practices miss out on pertinent information while making the transition from paper records to electronic ones.

• 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 pasting.

• 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 was present.

• 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

breakfast. • Physicians should take some time to understand their

systems, and educate themselves of the challenges and opportunities EMRs provide.

• Customizing EMRs.

Thank You…!!!

For more details

call

877-272-1572

or visit

www.medicaltranscriptionsservice.com