“Recently, a jury in Florida returned a verdict of $7.5 million against a pediatrician who neglected to tell a mother or other doctors that her daughter had a dangerous heart condition which later killed her (Rowe v. Wickham Pediatrics/Dr. Agha). The circumstances surrounding this incident highlight a breach of a doctor’s duty of care to his or her patient where there was an omission to maintain an accurate record of treatment provided to the patient and subsequent failure to diagnose a dangerous cardiac condition. Failure to maintain comprehensive medical records may ultimately compromise the ongoing care and management of the patient. The circumstance surrounding the above case clearly demonstrates the failure of adequate record keeping skills. In the above case, the Pediatrician and ER doctor failed to document critical information in the patient’s medical record that ultimately led to a catastrophic outcome.”

Medical records remain an important tool in treating patients, but they’re often overlooked regarding their importance and the way they’re maintained. In many cases, medical documentation is handled by employees who have a heavy workload and not enough time to devote to making sure records have every detail properly noted. But an emergency department, physicians, and staff need to work extra hard on this vital task. Let’s take a look at why accurate documentation is crucial.

1. Improved Patient Outcomes:

Research has shown that keeping proper medical documentation improves a patient’s clinical outcome after he or she leaves the hospital. Many of the problems patients experience after discharge – from infections to harmful drug reactions – are the result of delayed or incomplete information given to healthcare providers. Moreover, patients who had gaps in their health records spent a longer time in emergency departments than those who had complete documentation.

2. Vital to Claims Processing:

It’s only through good documentation that claims processing and reimbursement can be done in a timely and error-free fashion. In fact, experts say proper reimbursement is almost entirely dependent on good record-keeping. The rest comes down to knowing the rules set down by the federal government and other organizations.

3. Improves Quality Assurance:

Insisting on accurate documentation regarding initial assessments and progress notes plays a key role in quality assurance. It forces practitioners to think carefully about what they do while developing a self-reflection that is important to maintaining their skills, professional development, and providing quality care in the future. Good documentation also allows members of a treatment team to learn from each other and coordinate their approaches to a patient’s overall care.

4. Clinical Details Are Compiled in One Place:

Having clinical details in one well-maintained document helps a medical practitioner remember crucial events and treatment. By recording all of a patient’s complaint and symptoms, practitioners can identify trends that help guide them in the development of a treatment plan.

5. Good Medical Documentation is a Defense against:

Malpractice Most medical experts agree that best defense against a malpractice claim is proper documentation. If a procedure is not listed on the patient’s chart or another document, then judges and juries have no way of knowing if it was done. Strong record-keeping is also crucial in dealing with abusive patients, patients who don’t follow advice, or patients who come back with the same complaint without improvement.

Inaccurate medication history at admission leads to adverse drug events which in turn causes mortality, morbidity and healthcare costs. Medication history errors are extremely common and are a concerning issue. Omitting drugs erroneously is one such common concern. The adverse hypersensitive reactions that certain drugs cause needs to be recorded more carefully. But more often this key information is poorly documented or not explored in detail. Even the alternative drug that was provided should be recorded.This is why you need a proper nursing care expert team to make the correct documentation.

“If it’s undocumented in the medical record then it didn’t happen.” How many times have the plaintiff’s counsel used this in the courtroom? It’s an age-old saying, but the reality is much happening that doesn’t get documented. The real issue: is the documentation in the medical record complete, accurate, and concise (and yes, timed/dated). Ultimately the necessity for all healthcare professionals is to ensure they keep accurate, timely and clear medical records. Inaccuracies or improper record keeping may have devastating consequences for the patient and all concerned in the care of the patient.