Health care risk management strategies and implementation

Healthcare Administration

Risk Involved in Poor Chart Documentation: An Overview in Total Quality Management

Poor chart documentation in the behavioral health field is a concern for risk management and a critical area for total quality improvement. Poor chart documentation can lead to an audit by accrediting bodies and in severe circumstances lead to discharge. There are many legal ramifications associated with poor chart documentation. This paper will highlight the importance of poor chart documentation, the consequences of poor documentation, and suggest possible tools for resolving documentation errors. The best tool for eliminating chart documentation risk is developing a risk management system appropriate to the health care setting.

Poor chart documentation costs behavioral health providers thousands of dollars in malpractice costs every year. Errors related to chart documentation can be severe; a patient can suffer an untimely death for example. In fact, statistical evidence suggests that each year thousands of patients die or are injured resulting from documentation errors, whether the result of a medication error, or a failure to document critical health history (Carroll & Brown, 2006; Youngberg, 2010; Burke, Boal & Mitchell, 2004). Other errors include illegible orders, the failure to receive a physician's orders in time resulting in inadequate care or misread orders (Youngberg, 2010). In some facilities, patient safety care officers are enlisted to help resolve problems that seem "unresolvable" (Youngberg, 2010). The problem is much more complicated however, than simply enlisting the help of a safety officer. A safety officer can help identify errors but may not be able to resolve a systemic problem without the help of the entire healthcare team.

Physicians suffer from poor documentation as much as patients, as do nurses and other health providers. The consequences of poor charting are numerous; they can result in denied claims as well as injuries, as mentioned previous. A physician can lose their medical license because of poor documentation, especially in the event of a severe injury or patient death. Audits are also a likely event if patient health suffers because of charting errors. An entire organization may be liable for charting errors. This is a very serious affair that cannot be taken lightly. Audits can cost organizations thousands of dollars in liability. Often poor documentation is a factor that plays in failure to accurately diagnose a patient, and many medical malpractice claims (Carroll & Brown, 2006). Good diagnoses are critical in the behavioral health field, making adequate chart documentation even more critical in the behavioral health field.

One of the methods to reduce charting errors is to utilize technology; electronic charting for example, instead of handwritten charts can help reduce errors associated with illegible handwriting. (Youngberg, 2010 p. 438.) Carroll & Brown (2006) suggest a "risk management process" must be enacted that includes five steps which including selecting the best risk management technique, implementing the technique and monitoring its success (p. 13). As part of this process risk identification would be necessary as would risk reporting. In the case of chart documentation, a survey of the number of chart errors would be necessary. If a hospital would switch to electronic chart documentation, it would be helpful to compare chart errors prior to electronic chart data, and after; human error in chart documentation due to inputting of data in an electronic system is just as likely as chart error while inputting data into a hard copy chart. Therefore, effective measures would need to be put into place to reduce the odds that errors might be made while inputting data into an electronic data systems, just as they would have been put into place while inputting data into a hard-copy system. Risk management is just as much a checks and balances system as it is anything else. It is a "patient care process" (Carroll & Brown, 2006, p. 15) that helps minimize risk and allows risk managers and health care providers to capture and prevent incidents that may jeopardize patients health and physicians liability.

Key points to charting include: (1) legibility, (2) alterations, (3) accuracy, and, (4) timeliness. There are times when medical records must be changed. In these instances, the best thing to do is copy the original record, and then places any changes on top of the original document. In this way, the original document can still be reviewed in the event a malpractice claim is made. Too often, the original record is deleted, and claims can be made for false practices.

With regard to documentation there are still few providers that routinely taking advantage of electronic medical records; many instead continue to dictate medical records, outsourcing transcription to foreign providers (Carroll & Brown, 2006). This again, must be addressed with regard to regulatory compliance and risk management (p. 436). There are several measures that can be put into place to limit the risks associated with transcription error and error resulting from mismanagement of records or other errors associated with charting (Aron & Headrick, 2002). For example, voice recognition software is readily available that physicians and nurses could use to dictate their notes directly into a computer system; such measures would allow transcription to occur simultaneously, eliminating the need for third party transcription. While such technology is far from perfect, it could be used as part of a systematic process in a comprehensive risk management program.

Clinical guidelines should take into consideration that statistical probability of future errors compared to the likelihood of reduced risk, or they should weight the benefits and risks of introducing a new approach to charting. The potential benefits of utilizing a more efficient system may outweigh any new risks associated with using a new system. It may also prove more efficient for physicians and other caregivers, improving the total quality care offered patients. In the event of an audit, an electronic charting tool using voice recognition software or some similar component may prove more beneficial as well, allowing easier access to patient information.

Conclusions

Reducing charting errors is critical for physicians in the behavioral health field. In any medical field it is critical to chart patient history, status, and progress. This is for the best interest of both patient and healthcare provider. There is no perfect measure for eliminating the risk of charting errors; however a systematic approach to reducing charting mistakes is necessary. Total quality control measures ensure the best possible care is provided to patients, and help limit the liability associated with patient errors. Fortunately there are many tools available from which to choose to help reduce the risk of error.