How to Prevent Missing Medical Records

00:11 Importance of Maintaining Accurate Medical Records

It is critical to maintain medical records to provide quality patient care. Any missing record also carries the risk of legal liability. Medical charts that are well-prepared and stored can assist in the successful defense of a legal action. Attorneys mainly require these records to demonstrate the various medical encounters of the plaintiff and their outcomes. While collecting records for use in cases pertaining to personal injury, medical malpractice, Workers’ Compensation or product liability, identifying missing records is a key process. Healthcare providers and attorneys can benefit from the services provided by a medical review company to identify any missing records.

Missing medical documentation often includes inadequate, unsigned progress notes, records that are unauthorized or without the provider’s signature, and documentation of intent to order procedures/services. Healthcare providers can use professional medical review services to perform chart audits that would assist in evaluating the quality and accuracy of their medical documentation.

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01:18 Tips to Prevent Missing Medical Documentation

• Ensure that the record adequately shows the patient’s health details
• Clearly document medicines prescribed, administered, and renewed
• Document all instructions and information given to the patient
• Record all communications made with the patient’s family/caregiver
• Document all vital signs consistently and in a timely manner
• Document the recommended follow-up visit date
• Document each mode of patient contact
• Implement a well-designed EHR system
• Turn on the audit facilities of the EHR system
• Ensure that no blank lines exist between entries

A comprehensive medical review can identify the patient’s demographic details, medical records that are missing or missing information, the concerned hospital or medical service provider from whom the missing information is to be retrieved, date or period of the record, why the specific medical record is needed, and other data. Missing medical records signify that the care provided was inadequate or incomplete, and also suggests non-compliance with the policies of the organization.

Thank you for listening and please feel free to reach out at (800)-670-2809.