Question:
Dear Nancy,
I was taught to correct a charting error by drawing one line through the error, initialing it, and rewriting. I was also told not to use Wite-Out. Is there any place that defines this more? Is it a law? What can happen to a nurse who uses Wite-Out and writes over it or crosses words out with multiple lines? I am a director of operations and have one nurse who uses Wite-Out and writes over, especially dates, so I don’t know what the original date was. Can you direct me to where I can learn more so I have something to back me when I approach this nurse with these issues?
Mariska
Nancy Brent replies:
Dear Mariska,
Your understanding of how to correct errors is indeed accurate. The use of Wite-Out and then writing over the dried Wite-Out raises many questions legally, not the least of which is the one you raised: What was in the original documentation?
There are many excellent texts on legal issues in documentation. You can identify them by placing documentation in the medical record in your browsers search bar and then reviewing the results. In addition, there are many state and federal laws that govern documentation in the medical record and what is required for entries, corrections, etc. Some of those laws include The Health Care Insurance Portability and Accountability Act [federal] and The Medicare and Medicaid Statute [federal]. State laws include rules for licensure of healthcare facilities and nurse practice acts. Private accreditation agencies also mandate documentation requirements.
It may be helpful for you to consult with a nurse attorney or attorney in your state who can provide an in-service on the principles of good documentation and how suspicious corrections or additions to a record may result in liability for the hospital and those involved if there is a patient injury or death [professional negligence suit], questionable billing practices [fraud and abuse], or false documentation to cover a particular patient situation.
At a minimum, your risk manager should be alerted to this problem so that he or she can begin an in-house review of records and institute better policies to eradicate this practice. If the policies governing documentation are not followed, the nurse manager should be able to initiate disciplinary action against those employees who continue to violate established documentation policies.
Cordially,
Nancy
Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.
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Highlights
•
This study has determined that as a result of the file review, errors in medical records will be reduced by a pre-determined amount.
•This is the first research in Turkey that makes mistakes in the medical patient records based on examining the patient file.
•The integration of the hospitalization consent form into the hospital information management system was recommended.
This study demonstrated the importance of training in reducing medical records and patient file errors.
Abstract
Aim
The purpose of this study was to reduce the errors that might occur in the medical practice records to the lowest possible level, thereby contributing to a better quality of health care services. The aim of this study is to reduce the errors and deficiencies in the patient files by providing training related to medical records and patient files to the personnel who are responsible for filling the patient files. This study was based on medical record errors in patient files.
Method
The study was carried out in a training and research hospital in the Turkish health sector, and 360 physicians, nurses, and medical secretaries took part. In this context, the mistakes in the patient files were monitored and recorded, the recordings were analyzed to determine error areas, and the participants were trained to enter patient files correctly and completely.
Results
The error-free patient file rate was 9% in the first month of the study. In the second month of the study, the participants were trained to properly complete the patient's files. The error-free patient files rate increased to 35%, 41%, 69% in the second, third, and fourth month of the study, respectively.
Conclusion
Our data demonstrate the importance of educating health workers to prevent mistakes in medical records. Our data also demonstrate the necessity of using electronic medical recording systems. All health institutions should move into regular, accurate, and complete recording systems to prevent medical errors that might arise in terms of patient and employee safety, thereby helping to fulfill their legal responsibilities.
Keywords
Medical record errors
File control
Electronic medical records
Medical informatics
Patient files
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© 2019 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.