Keeping excellent medical records is significant for continuity, especially at instances where several clinicians are required to offer care. Therefore, proper record keeping is a fundamental part of outstanding medical care. However, this is no always achieved in most medical facilities. There are various pitfalls that influence the ability of an office to maintain proper records.
One pitfall is the omission of required information (Ziesemer, 2013). If the clinician states that certain information should be included in a medical record, the record keeper should ensure that the information or the items required are involved.
The second pitfall is the use of bad language. According to the medics’ ethics, record keepers should be professional enough to maintain positive remarks about the patient. Accurate and pertinent information should be recorded properly (Ziesemer, 2013). Patient’s and care provider’s words should be taken seriously and recorded accordingly.
The other pitfall is based on illegibility of records. All records should be read easily and they would serve no purpose if they cannot be read (Ziesemer, 2013). Records are kept so that they can be read and reviewed by another person in future.
The other pitfall that may be avoided is the use of too many abbreviations (Ziesemer, 2013). Excessive abbreviations mean that a key needs be consulted from time to time to give the meaning. Excessive number of abbreviations means that there will distinctively be confusion to another person who will visit the records in future.
Although, errors are common during recording they should be avoided to the highest point. If they occur, they should be corrected immediately to allow maintenance of high quality information which is not ruined by misplaced information (Ziesemer, 2013).
Omission for relevant information is another common pitfall in record keeping process. It is usually said that if it has not been recorded it did not occur (Ziesemer, 2013). If critical information on a given test was not recorded it may cause a lot of confusion to another provider who may be assigned to take care of the patient in future.
Therefore, critical care is needed while handling medical records and despite the size of the clinic records should be kept right. Medical records are sensitive and needs keenness in keeping them to avoid confusion in future.
Work Cited
Ziesemer, Brandy G.. Medical office management and technology: an applied approach. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2013. Print.
