Errors In Medical Documentation

The initial search of the systematic review resulted in 3,607 articles from the five databases chosen for the search. After specifying the inclusion criteria of “clinical documentation,” “documentation errors,” and “physicians” as well as the exclusion criteria of “nursing,” the final number of articles included were 15. The articles reviewed clinical documentation process and strategies along with the impact of documentation errors made by physicians. A summary of the articles can be seen below in Table 1.
Documentation Errors and Financial Correlations: Zhang et al. (2013), copy and pasting within electronic medical records was discussed. There are many advantages to using an electronic system such as saving time and helping to make decisions
Complete and accurate clinical documentation will help to improve the quality of care given to a patient and will also aid in financial claims for patient encounters. Clinical documentation programs can be very beneficial for physicians to be involved and aware of what information is needed for a complete record. There are also software systems that can aid physicians in completing all necessary fields for a record. These systems can aid or harm documentation by allowing copying and pasting or inputting less details (“The right documentation strategy,” 2013). Not only have these systems been a challenge to documentation, the implementation of ICD-10 has also had an impact on medical error. If records are not complete and detailed and contain errors in documentation, coding will also contain errors and effect payment systems (“The right documentation strategy,” 2013). This article discusses the importance of proper clinical documentation without errors and impacts complete charts have on increased