Healthcare Administration
Risk Involved in Poor Chart Documentation: An Overview in Total Quality Management
Poor chart documentation in the behavioral health field is a concern for risk management and a critical area for total quality improvement. Poor chart documentation can lead to an audit by accrediting bodies and in severe circumstances lead to discharge. There are many legal ramifications associated with poor chart documentation. This paper will highlight the importance of poor chart documentation, the consequences of poor documentation, and suggest possible tools for resolving documentation errors. The best tool for eliminating chart documentation risk is developing a risk management system appropriate to the health care setting.
Poor chart documentation costs behavioral health providers thousands of dollars in malpractice costs every year. Errors related to chart documentation can be severe; a patient can suffer an untimely death for example. In fact, statistical evidence suggests that each year thousands of patients die or are injured resulting from documentation errors, whether the result of a medication error, or a failure to document critical health history (Carroll & Brown, 2006; Youngberg, 2010; Burke, Boal & Mitchell, 2004). Other errors include illegible orders, the failure to receive a physician's orders in time resulting in inadequate care or misread orders (Youngberg, 2010). In some facilities, patient safety care officers are enlisted to help resolve problems that seem "unresolvable" (Youngberg, 2010). The problem is much more complicated however, than simply enlisting the help of a safety officer. A safety officer can help identify errors but may not be able to resolve a systemic problem without the help of the entire healthcare team.
Physicians suffer from poor documentation as much as patients, as do nurses and other health providers. The consequences of poor charting are numerous; they can result in denied claims as well as injuries, as mentioned previous. A physician can lose their medical license because of poor...
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