Common Errors that Result in Poor Healthcare Documentation

Healthcare Documentation

The healthcare system is largely based on healthcare documentation or medical transcription which when accurate and complete can bring a lot of efficiency in handling a patient’s history and improving the care provided thereby affecting the overall healthcare system. Healthcare documentation involves the transcription of the physician observations regarding a patient visit which include patient demographic details, their complaints, the physician’s diagnosis, medicines prescribed, tests advised and treatment method followed. This is done by the transcriptionists or healthcare documentation specialists who listen to the audio files sent by physicians and type those details in a prescribed format given by the healthcare provider.

Since the healthcare documentation jobs deal with the sensitive data of patient health, it is of utmost significance that the transcription reports are accurate and complete so as to provide the best quality health care and to avoid making any kind of wrong decisions by the physicians in offering medical services. However, due to various reasons, transcriptionists may err while preparing transcription reports which can alter the course of action of physicians and affect the health of a patient negatively. In order to reduce errors, it is necessary to understand the areas where transcriptionists may err and take measures to avoid such errors. Here listed are some of the most common errors in medical transcription.

  • Grammar errors: Healthcare documentation jobs involve listening, interpreting and typing the data given by physicians into a prescribed format. This means that the transcriptionists have to put all that the doctor has said in a written document and this has to be done perfectly with correct spelling and grammar. Grammar plays a critical role in the transcription process because improper grammar increases the chances of giving a wrong interpretation of the patient notes thereby giving scope for wrong decision making of the doctors.
  • Spelling errors: Transcriptionists may err in spellings that sound alike but differ in meanings or in spellings that have the same spelling but differ in meaning. Such errors can spoil a report by making it inaccurate and useless. Wrong spellings can alter the context or meaning of the sentence and affect the decision-making of the physicians.
  • Numerical errors: There is a lot of importance of accurate numerals in the healthcare industry while reporting values assigned to functions of organs, cells, hormones, etc. Details of a patient case, follow-up requirements, diagnosis, and medication can go wrong if the wrong numerals are recorded. Dosage errors are an example of numerical errors where a wrong numerical is recorded for the medicine dosage.

Being aware of the common errors is the first step to avoid such mistakes and make a transcription report accurate and complete. People in healthcare documentation jobs should be careful while transcribing reports and ensure that their reports are accurate. Choosing the right healthcare documentation companies is the key to get accurate transcription reports that facilitate providing quality health care.

Common Errors that Result in Poor Healthcare Documentation