Things to Avoid When Maintaining Records
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.