Medical providers have to adequately maintain patient medical records at all times. The quality of these records become crucial when it comes to medical record reviews. Here are a few things that should be avoided when maintaining medical records.
Unreadable Records – if handwritten, make sure the information is accurate and legible. A reviewer should be able to easily read and understand the information within the record.
Overuse of Abbreviations – using too many abbreviations is considered bad practice as not all abbreviations are known universally.
Mistakes in the Records – errors should be avoided as much as possible; however, if an error does occur it should be corrected using the strikeout method. The date of the correction and the reason for the correction should be clearly stated.
Omitting Pertinent Information – tests, conversations with the patient, consultations with other providers, instructions given, and precautions taken should ALL be clearing noted in the records.