Healthcare professionals spend most of their day attending to patient needs, catching up on the latest research, and performing administrative tasks. Even with such a busy schedule, you must keep accurate and thorough medical records about the patients and each service they receive. While documentation is burdensome work that could distract healthcare workers from professional care, medical records are significant.

In California, medical records contain information such as the diagnosis, treatment, medications, and care given to the patients. Failure to maintain proper documents will harm the patient's well-being and jeopardize your career. Some medical record mistakes can result in probation or professional license revocation.

You will require the guidance of a healthcare license defense lawyer if your professional license is at stake due to a medical record error. Your attorney will help you investigate the circumstances of your mistakes and defend your license against suspension or revocation.

The following are some medical record mistakes that can destroy your career:

Medication Information Errors

Medication information is a significant part of a patient’s medical records. In most cases, the prescription of medications is the last step in the treatment process. After a medical examination and procedures, the doctor will prescribe medications that the patients will receive. The patients take the medicines at home or administer them at the healthcare facility.

Medication errors can be risky for a patient’s health. Many prescription medications can have harmful interactions with other drugs. Some critical information that should be part of the medication information record includes:

Medication History

As you document your patient’s medication information, you must include any medications they could take. This includes over-the-counter medicines, herbal drugs, and illegal substances. Including this information helps determine how the medications prescribed for their condition would react with the medicines they already take.

Another benefit of noting the medication history is avoiding overdosing the patient. If the patient is already on the drug you seek to prescribe, their history could help determine the dosage you must administer.

The medication history may also be beneficial in determining a patient’s overall health and possible reaction to different types of drugs. You gather information on medication history from the patient’s testimony and other medical records.

Allergic Reactions to Medication

Another component of medication information that you must indicate in a patient’s medical record is the presence of allergic reactions to medication. During the initial stages of treatment, you must ensure a patient’s history of responses to particular drugs.

Before you issue or administer a prescription, you must refer to these records to determine if the medications suit the patient. Some allergic reactions to medications can cause serious medical complications or the victim's death.

If a patient is injured due to an allergic reaction to medication and you do not have the record, your professional license could be at stake. Therefore, you must avoid omitting or ignoring any information about the patient.

Correct Prescriptions

In most cases, the doctor who prescribes mediation will not be the one to issue or administer the drugs. After a diagnosis, you must indicate the type and dosage of medication a patient needs for their particular condition.

Omission of medication or recording the wrong prescription can result in serious injuries. The underlying condition will not be resolved when a patient ingests the wrong drug. Additionally, the patient could suffer more complications that can be risky for their health and well-being. You can be sued for medical malpractice when a patient receives the wrong prescription due to a medication record mistake.

Incorrect or Missing Diagnostic Information

Healthcare professionals rely on the diagnosis information when administering medication or performing surgical procedures. Even after the doctor has made the correct diagnosis, proper documentation of the findings is critical. You must include all your conclusions in the patient’s medical record. This makes it easy for other medical practitioners to provide the necessary care.

Remember to indicate the diagnosis or have the information mixed up while you are busy tending to patients and updating yourself on new information. Incorrect or missing diagnostic information could have life-threatening consequences. A patient may have to deal with a lifelong medical issue or disability due to a minor record mistake. Some of the expected consequences caused by a diagnostic record error include the following:

  • Unnecessary surgical procedures. When you indicate incorrect information or omit critical information when recording a patient’s diagnosis, they may be subjected to unnecessary surgical procedures. Surgical procedures performed without justification can be risky for the patient’s life. Sometimes, the patient may lose a healthy organ or die from the error.
  • Administration of the wrong medication. When the information on the diagnosis report is inaccurate or omitted, the patient could receive inappropriate medications. In cases where the patient is allergic to the medication administered, they could suffer serious injuries or die. Therefore, indicating the accurate details of the diagnosis will help avoid mistakes by other practitioners.
  • Delayed treatment. In cases where the diagnosis for a particular condition is missing from the medical records, the patient needs to receive the necessary treatment on time. Even when you have made the correct diagnosis, omitting the information can deny the patient the right to timely treatment. When some conditions are not treated in time, they could progress and become more complicated.

Inaccurate or Missing Medical History

A patient’s medical history is key before any treatment or healthcare. Even when a person has never been to your facility, you must ensure to take their history. The components of a patient’s medical history include:

  • Past diagnosis. If a patient has been diagnosed with a severe medical condition in the past, you should not use the information in their medical record. This diagnosis may help determine the cause of their current situation and direct other practitioners on the steps to take.
  • Ongoing treatment. When a patient visits your facility with a medical condition, you must ask about and record their current health. If the patient is undergoing other forms of treatment. This information should be clear to anyone who handles these records.

The primary purpose of documenting a patient’s medical history is to help create a healthcare plan. Different factors in their medical past could help determine the type of treatment and procedures they need. Additionally, the record will help other practitioners decide on the proper care form.

Failure to record or incorrect recording of a patient’s medical history could result in improper diagnosis and treatment of the patient. A missed diagnosis or inappropriate treatment may result in the progression of the medical condition. If you fail to record a patient’s allergies to certain medications, another doctor who relies on your records may prescribe a drug that produces severe allergic reactions in the patient.

Doctors and other healthcare professionals have the relevant training to obtain and document a complete medical record for their patients. Failure to do this can harm the patient and also count as medical malpractice, which can be detrimental to your career. You could avoid this medical record error by documenting every detail of a patient’s medical history.

Patient Misidentification Errors

A critical component that must be found in the medical records is the patient’s identification information. Before indicating the medical history and information on current treatment, you must ensure that the patient’s personal information is clear. Identification information includes the patient’s:

  • Date of birth.
  • Official names.
  • Marital status.
  • Social security number.

Patient identification record errors have been an issue in the healthcare sector even before the advancement of technology. Even with the introduction of electronic health records, mistakes still need to be made. Inaccurate or missing patient identification information can have the following consequences:

Failure to Receive the Right Treatment

The documentation may be mixed up when you incorrectly indicate a patient’s information. This could prevent the patient from receiving necessary care. When health professionals do not know the rightful owner of some medical reports, offering the proper care could be challenging.

Wrong Administration of Medication and Surgeries

Mixing up patient identification information is a standard medical record error. If you are busy entering multiple patient records, putting the wrong identification information on the right medical report is easy. This could cause a patient to receive treatment or undergo a procedure for another patient.

Billing Errors

The patient's information is the first element that helps determine the billing information. The hospital may undercharge or overcharge patients if the wrong identification information is indicated on a medical record. Additionally, a patient’s insurance company may receive a bill for services their client did not receive.

The billing department is critical to the profitability of the healthcare facility. Therefore, in the case of billing, the facility can suffer financially. If your misidentification error causes a patient to be overcharged, they could file a lawsuit against you. When your professional licensing board learns of this error, they could seek to suspend or revoke your license.

Wrong Discharge

When you misidentify a patient through incorrect or omitted information on the records, they could be wrongfully discharged. If a patient has been admitted to the hospital for serious medical issues, discharging them without providing the necessary care could harm their health and well-being.

When a patient or their family finds out they were wrongfully discharged, they can file a medical malpractice lawsuit against you and the healthcare facility. Your licensing board expects you to be careful when drafting medical records. Failure to do this will result in a malpractice investigation and a possible career loss.

Misplaced Consent Forms

In California, patients are allowed to make decisions about their healthcare. Therefore, you should prepare consent forms for the patients to sign before undergoing major procedures or before you proceed with treatment. Information that is included in the consent forms includes:

  • Chances of recovery.
  • Diagnosis.
  • Benefits and risks of recommended treatment.
  • Challenges with recovery.
  • Future complications associated with the treatment.

If you fail to offer or misplace the patient consent forms, your career could be in jeopardy. This is because when patients suffer severe negative consequences from treatment, they could argue that they did not consent to the procedure. The consent forms in their file may be the only way to prove the procedures were justified.

Treatment History Mistakes

A patient’s treatment history is another critical part of medical records. The treatment history could contain the following information:

  • Patients history of illness.
  • Vital signs.
  • Results of a physical examination.
  • Family history.
  • Surgical history.
  • Diet and lifestyle.
  • Developmental history.

When this information is clear, patients can receive customized care for their medical issues. The omission of a patient’s treatment history could negatively change the outcome of their treatment. For every procedure you recommend or drug you administer to a patient, you must ensure that you indicate it on their record. This helps you reference and justify each action that you take.

Medical Directive and Treatment Record Errors

Medical directives are the final orders on the procedures and medications that patients should receive for their medical issues. Additionally, these directly outline the patient’s wishes if they cannot communicate their needs.

The treatment records, however, indicate the patient's treatments since entering your facility. Failure to keep proper records on these directives to avoid administering wrong or unnecessary procedures.

Messy Handwriting

Poor handwriting is a minor issue. However, in medical settings, messy handwriting may cause serious harm to patients. Your poor handwriting may result in serious medical errors that translate to your professional handwriting loss.

When the information you indicate on a patient’s medical record is not legible, other medical professionals may have a challenging time interpreting the information. Healthcare practitioners may be too busy and lack time to seek clarification. Therefore, they will use their interpretation to continue the care process for the patient. The wrong interpretation of medical information can result in other severe medical errors.

Wrong use of Abbreviations

Healthcare professionals need help dealing with their daily tasks while trying to upgrade their services for patients. The medical world is full of complex and ambiguous terminology, which can take a while to note down while the doctor or nurse speaks with the patient.

The use of abbreviations is a time saver when recording medical information. However, improper use of the abbreviation may risk your patients and career. Communication between healthcare professionals is critical to providing proper healthcare for all patients.

Therefore, whatever you document may be used by another practitioner to administer medications or continue the care process. When you use the wrong abbreviations, other practitioners will make correct interpretations, which can result in the provision of unnecessary services. Some of the risks of using abbreviations include:

  • Confusion and misinterpretation. Sometimes, you may be the only person who understands the meaning of your abbreviations. You could send your notes as you give your patients the instructions they need to follow for medications and procedures. These notes could be filled with acronyms that they cannot comprehend. In this case, the patient will either return to you for an interpretation or guess what you meant with the information. Following the wrong interpretation can affect the health and well-being of the patient.
  • Abbreviations cause legal trouble. Beyond the medical complications that could arise from incorrect abbreviations, you could be in serious legal trouble for the mistake. When the record error is reported to the licensing board, you will be called upon to interpret it. If the abbreviations you used deviated from the long list of accepted abbreviations, your license may be suspended.

As a healthcare practitioner, you can avoid abbreviation mistakes and protect your career through these care exercises:

  • Try to be consistent with the abbreviations you use.
  • Minimize the use of abbreviations during documentation.
  • You should seek clarification on abbreviations before using them.
  • Keep track of facility-accepted abbreviations. This helps ensure that the other practitioners who use the records can adequately understand the information you indicate.
  • Read a list of accepted abbreviations.

Find Expert Legal Professional License Defense Guidance Near Me

Healthcare professionals and hospitals must keep detailed medical records of their patients and all the services they provide. Medical records are essential to healthcare because they offer information about the patient’s medical history and highlight any restrictions. Additionally, these records help account for the services given for reference in case a patient encounters a problem with treatment.

Although taking time out of your busy schedule for documentation may seem unnecessary, errors in these records can cause serious injuries or the patient's death. Some common medical record mistakes you could make include omitting patient information, including the wrong information, and transcription errors.

When a patient is injured or dies due to a medical record error, the family can file a medical malpractice lawsuit against you. Additionally, your professional licensing board may seek to suspend or revoke your license. You will benefit from our expert guidance at the Legal Guardian if you are accused of severe medical record errors. We serve clients seeking legal advice and representation to protect their professional licenses in Long Beach, CA. Contact us today at 866-448-6811 to discuss your case.