Everyone makes mistakes, it’s part of life. But when mistakes are made during clinical documentation and charting, things can quickly go south.
From claim denials to other issues, incorrect or incomplete documentation can be costly for home health care agencies. And for some, it can even lead to them shutting their doors.
While nurses and others in the field are on-the-go and just about always in a hurry, it’s important to make them aware of the most common errors to watch out for. But don’t worry. We aren’t just going to tell you about common errors. We’re also going to tell you how you can greatly reduce these errors and even eliminate them altogether.
6 Common Errors when Charting Patient Information
1. Illegible Handwriting
Communication is essential, especially when relaying medical information forward to multiple sources. The slightest mistake can put patients at risk and result in severe consequences.
A disturbance in communication is often caused by illegible handwriting. You must pay attention to minor details when it comes to medical terminology. For instance, there is a significant difference between “hyper” and “hypo” or “he” and “she”.
If the handwriting is sloppy and cannot be easily distinguished, then medication errors occur or more communication will be required to confirm the original message, which ultimately delays reaching the goal of fulfilling a patient’s needs.
2. Using the Wrong Abbreviations
The same problem occurs for abbreviations. Abbreviations in poor handwriting cause a tremendous amount of confusion, and for obvious reasons, you can’t rely on personal interpretation or the best guess of what the abbreviation could be.
One of the most common abbreviation errors in nursing documentation is “IU,” “stem” drug names and “TID” for nursing.
During the day, pharmacists come across multiple ambiguous abbreviations and must call the physician to clarify the misunderstanding. Due to the busy day each profession encounters, these calls don’t occur in a timely manner and leave patients waiting.
3. Incomplete or Missing Documentation
Every piece of documented information in a patient’s chart is essential in order to provide safe care. Waiting to record information later causes confusion and can create a sense of false progress or regression.
The medications that are prescribed, past medical history or treatment events rely heavily on the information in a patient’s chart so it’s important to have all the details present with the correct date, times, etc.
4. Lack of Medication Documentation
Both a patient’s past and present medical history is relevant when they are looking to receive health care. A mistake that is commonly made is not documenting a discontinuation of medication or past drug reactions, or changes in a patient’s condition.
Medication that has negatively impacted a patient in the past should be taken note of so that medication, or anything similar, will not be prescribed again.
Current medications are just as important. Medications that are currently being administered or taken by a patient should also be documented so that anything else given to the patient does not negatively react with it.
5. Failure to Record History of Prior Treatments
Recording medical history or prior treatments may give insight to reasons as to why patients may be experiencing certain symptoms. Details may reveal that a patient was under-treated and is suffering from its effects, or it may play a factor in a future diagnosis.
6. Recording on the Wrong Patient’s Chart
Believe it or not, recording on the wrong patient’s chart is a common mistake. When this occurs, not only does it put one patient at risk, but two, or even more. Organization is just as important as communication for effective health care.
Being extra cautious and performing even the simplest task with efficiency is the start to avoiding these common charting errors.
The best way to dramatically reduce charting errors? A smarter EMR System.
Charting mistakes happen; nurses are busy people. So how do we take charge to reduce the amount of these errors? One way we dramatically change is by adopting a smarter EMR system to document and chart patient information.
The right EMR software has the ability to catch errors before documentation or charting is submitted. With red flags and other validation measures, a reliable EMR system is going to prevent information from being submitted until all data is deemed accurate.
Using an EMR system that’s built specifically for home health care agencies has numerous benefits. Not only do these systems have the ability to save physical space and boost patient care, but they can also catch a number of errors, such as checking for treatment conflicts and avoiding duplicate tests, and ensuring all required information is entered prior to submission.
Learn more about Cubhub Home Care EMR Today
During a busy day filled with opportunities to make charting errors, there needs to be a solution to fix common mistakes.
And Cubhub is here to do just that. We share your goal of creating better outcomes for your patients and want to make your job easier, cut costs, and improve compliance by equipping you with an EMR system that truly has your back.
As a cloud-based EMR system with a Mobile App that your team can download right on their smartphone or tablet, we offer provider support, tools, and resources to pediatric companies to make patients’ lives better.
Schedule a demo with Cubhub today to take a step towards eliminating charting errors and improving patient care today!