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...
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…
