74% of medical malpractice claims are caused by incorrect or insufficient documentation.
(Medpro)
Medical documentation mistakes can cost PT practices dearly. Avoiding them at all times can save you a tremendous amount of time, energy, and resources.
To help you get started, here are seven common, costly medical documentation mistakes in PT practices and how to avoid them.
7 Common Fatal Medical Documentation Mistakes To Avoid
1. Incomplete Documentation
A 2022 study on medical records found that practices can lose up to $8 million a year due to missing medical data, which can negatively impact insurance reimbursement.
Incomplete documentation is among the most costly medical documentation mistakes and must be prevented or rectified immediately.
Enforcing guidelines, workflow protocols, and medical review sessions can ensure documentation completeness.
How To Avoid Incomplete Documentation
- Implement proper documentation guidelines that standardize note quality and formatting.
- Update patient information regularly for succeeding medical records.
- Conduct regular medical review sessions and audits to evaluate documentation completeness.
2. Getting Tagged For Cloning/Copy Forward
Cloning or copy forward is becoming increasingly common among healthcare professionals. However, it poses significant risks due to tagging issues that can lead to regulatory repercussions, affecting both the provider and the practice as a whole.
Cloning may still be effective in streamlining patient documentation in the long run, though it must be done correctly to avoid being tagged.
How To Avoid Getting Tagged For Cloning
- Enforce strict documentation protocols in which physical therapists must update all salient data from the recent patient encounter.
- Teach best practices on cloning that can help streamline the process while avoiding regulatory repercussions.
- Consider implementing a PT-focused AI scribe tool like ScribePT for saving time in documentation.
3. Data Inconsistency
Some patient data may become inconsistent throughout a patient’s treatment plan. This most likely happens when a patient switches providers, as differing documentation and EMR structures can cause data to be misplaced, miscoded, or lost altogether.
Inconsistent data can cause confusion and bottlenecks when identifying the next treatment steps for the patient. If the provider is unable to relay clear instructions immediately, the patient may be frustrated.
Ensuring data consistency is vital for identifying and providing the next treatment steps to the patient.
How To Avoid Inconsistent Data
- Check patient histories regularly to verify that the data is correct and up-to-date.
- Contact the patient’s previous physicians for confirmation of inconsistent data.
- When inconsistent data has been identified, correct it in the electronic medical record (EMR) to avoid future complications.
4. Omitting Vital Details
Some vital information may be missed in a provider’s notes during a patient appointment, which can lead to underbilling and improper treatment administration.
Teach your providers about efficient note-taking strategies. If all else fails, verify missing information with the patient by the next appointment to ensure the proper treatment is provided. You can also use a PT documentation tool to help capture all vital details during the encounter.
How To Avoid Data Omission
- Train providers on note-taking techniques (e.g., shorthand) to ensure all pertinent data is documented.
- Verify the missing information with the patient at their next appointment.
- Utilize an AI scribe tool like ScribePT to record the patient encounter with a transcript that captures all the details.
5. Incorrect Patient Information
Surprisingly, even with an EMR, incorrect patient information is still abundant. A 2022 STAT article on patient safety revealed that as many as 80% of patients had mismatched records in any one given clinic. This drops down to 50% in practices with shared EMR information.
Incorrect information can prove fatal not only in terms of the patient experience but also through devastating legal and regulatory repercussions that may occur when, for instance, medical malpractice is involved.
Thus, you must ensure that the correct information matches the right patient through regular verification and cross-checking.
How To Avoid Incorrect Patient Information
- Check current documents and records to validate the information.
- Confirm information with the patient at every visit.
- If the patient had a prior provider, cross-check the erroneous details with them.
6. Compromising Patient Engagement
61% of patients reported wanting better engagement and communication from their providers, according to a 2022 study published on TechTarget.
The overbearing burden of complying with billing guidelines can cause providers to focus more on documentation, affecting patient engagement. However, this can leave patients feeling disconnected from their providers, resulting in lower patient satisfaction and, potentially, churn.
Employing note-taking best practices, asking questions, and using AI tools are effective ways of maintaining patient engagement and note quality.
How To Avoid Compromising Patient Engagement
- Leverage note-taking best practices to ensure complete, direct engagement with the patient while noting vital details.
- Ask follow-up or clarificatory questions to catch details that patients may have missed.
- Use a PT documentation tool like ScribePT to take care of your notes as you fully engage your patient.
7. Provider Stress And Burnout
According to an athenahealth survey on healthcare technology, 58% of physicians reported increased stress levels due to feeling frequently overwhelmed by clinical data.
While creating accurate documentation is vital, you should also secure your provider’s well-being. Otherwise, they can become stressed and burned out, leading to lower productivity, decreased care quality, and even turnover.
Be sure to actively monitor and support your providers, prioritizing their welfare, and let them know you will help them with their needs.
How To Avoid Stress And Burnout In Your Providers
- Hold regular forums and workshops where providers can exchange ideas on coping with documentation burden.
- Ask for their feedback and recommendations on how documenting processes can be improved.
- Assure them vocally that they’re always welcome to share their grievances on note-taking and other aspects of PT documentation.
Always Hit The Mark With Your Patient Documentation
Practice goals can go awry when medical documentation mistakes are left unchecked. As long as you implement effective documentation best practices and protocols, you’ll be able to avoid these pitfalls while massively improving your revenue cycle in the long run.
Avoid costly healthcare documentation mistakes at your PT practices with ScribePT, the best AI scribe solution that utilizes cutting-edge speech recognition technology to transform your documentation workflow and take your practice to greater heights!
