MHRCM Solutions


(+1) 512 800 6431
(+1) 270 495 3261




Suite 101, 1250 S A W Grimes Blvd, Round Rock, Texas - 78664, USA

MHRCM Solutions


(+1) 512 800 6431
(+1) 270 495 3261




Suite 101, 1250 S A W Grimes Blvd, Round Rock,
Texas - 78664, USA

What Are the Common Errors in Clinical Medical Documentation?

By  Leo John

How often do you come across clinical documentation errors? If you are working in healthcare, then you should know that these errors are common and they can cost patients their lives.

Clinical documentation errors occur when doctors or nurses write down incorrect information about patient care. They can include things such as wrong medication doses, inaccurate lab test predictions or even missing vital signs. These errors can cause harm to patients and result in lawsuits against hospitals.

The importance of sound clinical documentation integrity cannot be overstated. Not only does accurate documentation reduce claims denials, but it also mitigates unbilled claims and slows down cash flow. By understanding what causes clinical documentation errors and how to avoid them, you can improve your RCM Healthcare Service process. YES, MHRCM offers clinical documentation consulting services that can help you improve your revenue cycle management process.

The cost of providing quality care is high, yet many people cannot afford it. According to the U.S. Census Bureau, nearly 20 percent of American adults cannot pay their medical bills. One fifth of these patients may never pay their bills. By communicating the costs of services upfront and clearly, practices improve their chances of getting paid for their work. An improved RCM process will help you communicate the costs of services and help patients understand them.
Clinical documentation errors are common in healthcare settings. In fact, they are estimated to happen at least once every five minutes. Though the errors cannot be eliminated, it can be minimized.

Clinical Documentation Errors:

Incomplete Documentation:

Incomplete Documentation is a common error made by the providers and found in most medical charts and leading to denial. Providers sometimes fail to provide information in the medical charts, as a result insurers make presumptions about the health information and complete the bill. Presumptions have a negative impact on both physicians reimbursement and patient care. Sometimes, missing documentation may lead to Medicare auditors and insurance carriers calling the provider to inquire about the documents.

Misplaced Document:

Misplaced documents are another common mistake in documentation. A common example of this is when procedure notes end up in the progress section, due to the many manuals involved. Sometimes the notes get misplaced when doctors create their own templates rather than relying on EHR templates. These errors are most common in facilities that use both electronic and paper records. These errors can cause serious problems for nurses and physicians who are often forced to work with incomplete data.
Copy-paste Issues:
A common error in EHRs is the copy-paste issue. EHRs enable users to reuse portions of the health record’s narrative. While copy-pasting the information, some sections are missed and incorrect copy-paste can harm the patients. Incomplete information is highly risky in health care. Missing a small piece of information can be fatal to the patient. It could also alert auditors looking for fraud and bring them to your door. A mistaken copy-paste could result in the addition of additional pages to a patient’s health record. This can slow down medical processes, including medical record reviews and could even lead to incorrect conclusions.

How to Have a Fail-Proof Revenue Cycle Management System in Healthcare?

Improve clinical Environment:

It is important for clinicians to feel comfortable with the information they are handling. Knowing what your staff and clinicians prefer to record documentation is far more important than what you would like. Some might prefer innovative technology, while others might prefer familiar equipment. It is possible to give staff a variety of options. This will ensure that staff are more comfortable with their work and provide better documentation. It will also help maintain equipment and a HIPAA compliant work process.

Outline Procedure and Process:

Clear guidelines for staff members and physicians will help RCM to meet the highest standards every time. Practice and Process should be included in the guidelines. It is always a clever idea to involve all parties in the development of the guidelines. It encourages everyone to be involved in the creation and maintenance of documentation. This approach is extremely helpful for all healthcare providers, especially those who specialize in a specific field of medicine.

Trained and Smart Transcription Team:

You should always have the best team to handle all your documentation needs. This team should include experienced professionals who are experts in documentation. These professionals are able to understand all facets of documentation. They have been trained to use industry best practices and deliver high quality work with minimum effort.
Stay focused on Specialty:

Outsourcing medical documentation is a better idea. However, it is important to match your transcription provider with your practice expertise. Look for vendors who are familiar with your practice. Service providers with extensive knowledge and experience can help you create flawless documentation.

Periodical Review:
Many organizations create guidelines but forget to check them at regular intervals. This can affect the quality of outsource medical documentation which, in turn, affects revenue cycle management. You should review your documentation process repeatedly. This will allow you to get staff feedback, solicit their opinion and ensure that high-quality output is achieved. These all contribute to continuous process improvement.
Improve CDI Efficiency:
Improving CDI efficiency will reduce time spent on RCM. Moreover, it will also lead to fewer denials and resubmissions. It will also minimize on-the-job frustrations for your staff. Ultimately, this will lead to lower turnover rates and better employee satisfaction. When data is accurate, patterns will emerge.
Streamline Registration Process:
Streamlining the registration process is another way to get rid of errors. By using patient portals, staff can upload and submit information about patients before their visit, saving valuable time for their team. This allows billing staff to complete stage two of the healthcare RCM process, which includes verifying insurance eligibility and out-of-pocket expenses. When this is done, the billing staff will have a clear picture of the care plan and can complete all required documentation quickly.
Mistakes in the outsource medical documentation process can be prevented by utilizing an RCM service. Outsourcing your RCM process to a third party can ensure the accuracy of your documentation, including ICD-10 codes and CPT codes. Furthermore, RCM Healthcare Se rvice companies are up to date on frequent billing guidelines. These experts have the latest technology tools. They are HIPAA compliant and comply with all relevant regulations.
Improving your revenue cycle management process is crucial to your practice’s success. Without a proper RCM process, your practice will face a poor financial situation, stagnant operations and unhappy patients. So, now’s the time to implement a revenue-cycle management solution for your medical practice.
Leo John

Leo John is a finance strategist and IT professional at MHRCM and is passionate about revolutionizing revenue cycle management (RCM).

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