Common Medical Record Documentation Errors | Jane Jackson, RN, CRC | RxEconsult

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Common Medical Record Documentation Errors Category: Healthcare Administration by - January 3, 2017 | Views: 45704 | Likes: 0 | Comment: 0  

medical record documentation errors

Common Documentation Errors That Cause Poor HEDIS And Risk Adjustment reviews

Medical record documentation is a critical component of quality reporting for health care plans.  Audits and reviews are performed for the collection of HEDIS (Health Information Data and Information Set) information and for the review of Medicare Risk Adjustment payment validations.  Many good medical records “fail” due to documentation errors.  I do not profess to be a documentation expert but I do recognize these common errors that cause charts to fail HEDIS and Risk Adjustment reviews.

Documentation is not legible

I have spent many hours trying to make words out of scribbles and squiggles.  Just for the record, someone besides the “author” of the medical record should be able to read the record.  It is not okay to assume what something says.  It shouldn’t be “scary” to ask the “scribbler” what something says.  Auditors and reviewers should not need to be able to read hieroglyphics to decipher a progress note.

At a minimum, handwritten documentation should clearly define the basics including the member’s name (first and last), the date of service, diagnoses with supporting documentation, and, just for the record, auditors/reviewers prefer the date of birth of the member on each documented date of service. 

Date of Service is not stated

The date of service needs to be clearly stated.  It is not acceptable to use the date the document was dictated, transcribed, signed or finalized.  It is also not acceptable to use the date when vital signs were recorded. 

HEDIS and Risk adjustment programs have certain date parameters when audits/reviews can be performed.  If the date of service on a record cannot be clearly established, the record cannot be used for quality and monetary reviews. 

Abbreviations are confusing

Use only standard abbreviations.  With the internet at your fingertips, there are many sources claiming to be the “all inclusive” medical abbreviations experts.  Be mindful that some abbreviations can easily be misinterpreted. For example,  I am an old cardiac nurse, to me MI means Myocardial Infarction but it also means Mental Illness.  If the provider wrote “History of MI” there could easily be two interpretations.  A statement “no complications with PMR” to me means the Pacemaker is functioning properly but to another reviewer/auditor, it could mean Polymyalgia Rheumatica. 

When there could be any doubt, write it out.  I learned that in nursing school a very long time ago.


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