Medical errors stem from a variety of reasons including poor communication, negligence and lackluster implementation of protocols. A critical part of patient safety is the documentation of every patient’s personal information, health history and treatment plans.
Health care providers who take documentation seriously can effectively reduce the chances of medical malpractice from happening.
Implications of mistakes
A host of serious problems can happen as the result of a medical error including chronic pain, worsening health conditions and death. According to CNBC, a study by Johns Hopkins revealed an alarming statistic stating that nearly 300,000 people die each year in the United States because of medical malpractice. What makes this statistic all the more disturbing is that medical malpractice is completely avoidable. Health care providers should prioritize patient safety and double and triple check their policies to catch potential errors before they create a hazard.
Making documentation effective
While each doctor’s office has unique ways of documenting patient information, certain practices can improve their methods. The American Academy of Family Physicians suggests a few tips to make documentation more thorough including the following:
- Documenting group discussions about a patient’s treatment and options
- Documenting individual thought processes related to a patient’s treatment
- Documenting the expectations for a patient’s treatment and recovery
Documentation can not only protect patients, but also doctors in the event a discrepancy arises regarding patient care. Vague or disorganized documentation lacks the information to help doctors make informed decisions which could ultimately put a patient’s life at risk. Proper documentation of patient information can provide insightful and accurate information that can help doctors properly diagnose, assess and treat patients in a customized manner.