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...
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…
Health Care Strategic Management The deliberative model in healthcare is expected to meet quite a few of the needs of the American public regarding the general area of healthcare. Of the many areas that may decide to look at this problem, an attempt is made here to look at two specific problems. One is the need of patients taking medicine properly and the other is the needs of patient care among
Health Care Quality Management as it Applies to Managed Care In the current age of improved answerability for quality of care, every healthcare expert should be conversant in the theory and paraphernalia of quality management) Quality Management-QM is an all-embracing attitude that pervades the management infrastructure, rules and customs of an establishment. It characteristically comprises of five fundamental doctrines -- undivided attention on the customer/supplier relationships; a stress on functional and
Healthcare Quality Management PDCA Modeling in Healthcare Psychiatric emergencies in medical settings may be particularly challenging since the staff does not encounter them frequently and may not have experience dealing with behavioral crisis intervention. The purpose of this exercise is to help staff improve understanding and coping with nonmedical emergencies that occur in medical settings using the PDCA cycle. X is a 41-year-old male admitted to a medical unit with a diagnosis of
Other ways to celebrate achievements would be to send thank-you cards, congratulatory notes, make phone calls, and send emails. 4. Being able to set challenging goals - people often strive to achieve what is expected of them, but if they are presented with a set of challenging goals they will work even harder to accomplish them. 5. Being able to provide the necessary tools to succeed - no team will stay
What emerges from these efforts are two essential understandings. First, in spite of whatever evidence may exist to the contrary, system building will continue apace in the hospital industry. Whether the battlefield is risky is immaterial, for the battle is joined. Some individual hospitals may decide to remain solo or stay in modest-sized systems where problems are more manageable, at least until some future time when some of the cloud
It may be most appropriate when there is a question of adding a new service or getting rid of a current service, but makes less sense for a department which is expected to continue in service. Incremental budgeting is a part of the rolling forecast system. If there is a sudden spike in revenue, for example, it may make sense to do an incremental budget to take into account the