Inadequate Patient Care Documentation and Its Consequences in the Emergency Medical Services (EMS)

Paper and electronic medical documents, ranging from physician and nurse notes to transliterated dictation, abound in the healthcare system. When the recording and documentation system is completely accurate and comprehensive, it works wonders in terms of displaying a patient’s medical history. To some extent, it aids in the improvement of patient care. Documents are required to maintain a consistent and adequate shared understanding of a patient’s attention history, which aids extensive intro and intropunitive communication and decision-making about the patient’s future care. These tools are necessary to ensure that the consistency, quality, and safety of attention are maintained across the numerous handovers that much medical staff involved in patient care produce (Drees et al., 2016).

However, at any place where documentation and recording are required, it is known that the primary purpose of the system is to speed up the flow of information that provides support to the steadiness, safety, and quality of care for the sick. Nonetheless, because record keeping and documentation system serve multiple purposes for instance accountability, financial billing and accreditation just to name but a few, tension is building up and is destabilizing the sole purpose of the documentation system. The pressure has powered incoherence of care, near misses and mistakes. The requirement of the joint commission and the plan of care are amongst the most specific types of recording and documentation. Nevertheless, planning and plans should simplify information movement across medical personnel there is little comprehensive evidence about their efficiency(Drees et al. 2016).

The documentation in the clinical records has to be thoroughly completed and perfectly accurate so as to facilitate a real variety of care. Nevertheless, nothing is perfect it turns out that numerous factors take a role in the development of poor recording and documentation including compliance concerns and time constraints. Turning on the other side, the problem of poor documentation comes with its effects and consequences (Drees et al. 2016). However, all problem have solutions, and the sooner the issue is acted upon, the faster we eliminate the predicaments. This paper discusses and expounds more on poor documentation and the consequences.

Poor Documentation

The first step taken before a problem is discussed or examined in the healthcare system, the organization must clarify if for sure the problem exists. After affirming that indeed there is a poor documentation problem the next step is to determine the details of what is the origin of poor documentation in the healthcare structure.Poor documentations can not be taken because the quality of documentation depends on who is handling the records. For instance for a poor physician documentation is one that impairs the patient’s evaluation or treatment. However, according to a coder documentation is that which lacks the sufficient specificity to assign an accurate diagnosis (Kodankandath et al. 2016).

General Consequences of Poor Documentation in a HealthCare Centre

Poor documentation inhabits clear presentation of the patient medical history. For instance in a case where a health care provider is documenting heart failure the individual has to include the acuity and type of the heart failure instead of just recording heart failure. The potential consequence of poor documentation is endless. Secondly, poor documentation may cause dire financial repercussions for the health facilities in term of a lawsuit by patients who have been misdiagnosed as a result of the inaccurate recording of information. Also, inaccurate documentation will most definitely lead to incorrect reimbursement of funds (Drees et al. 2016).

Patient and physicians rely on healthcare documents to make decisions concerning their health, with inadequate or inaccurate documentation it would lead to incorrect treatment decisions by the doctor or the patient. In the case of unclear communication between the consultant and the referring physician due to poor documentation can result in a lack of follow through with evaluation and treatment plans.It might lead to costly and unnecessary diagnostic studies (Drees et al. 2016).

Consequences of inaccurate Documentation in the EMS

Failure of comprehensive documentation of the Emergency Medical Services has a terrible outcome for patients. The EMS is associated with severe cases of poor recording and documentation or complete lack of documentation. In some cases, the EMS is affected by bias introduction of patients from referral medical units. Poor documentation in the EMS puts the patient’s safety at risk since the information flowing from the EMS officer and to the physician is inaccurate and that may cause misinterpretation and misdiagnosis of the patient in question (Kodankandath et al. 2016). In the prehospital settings, the cases of medication mistakes are on the rise as a result of inaccurate documentation. A medication error is a preventable event that can lead to inappropriate medication use which may cause harm to the patient while the medication is under control of healthcare provider. Poorly written protocols to follow-up while administering medication has led to an increase in case of medication errors. In this case, a patient can be subjected to medication underuse, medication overuse or drug misuse. For abuse cases, they occur when a medication is misused.This compromises safe patient care since the life of the patient is at risk (Kodankandath et al. 2016).

As clearly seen inaccurate or incomplete documentation most of the time causes the incorrect quality of services provided, and more so the health of the patient is compromised. Also, it contributes to poor and ineffective healthcare by another healthcare team that is going to attend to the patient later after being delivered to the medical facility. In cases where the patient has been overbilled because of inaccurate registry of the data by the EMS that rippled over to the hospital, it can lead to charges of fraud (Kodankandath et al. 2016).

Finally, the cases of incomplete documentation in the EMS has been linked to high mortality rate. Which is virtue due to misdiagnosis, wrong administering of drugs and improper flow of information to the other medical practitioners? The consequence that affects the medical officer is that they can face an allegation of fraud and can even lose their practicing license in cases their errors led to a patient’s death (Kodankandath et al. 2016).

Conclusion

It is evident that lack of Emergency Care Documentation of physiology is related to worse patient outcome. However incorporating simple measures of proper documentation of specifics may facilitate appropriate intervention and improve patients care. However, to deal with the problem of poor documentation, it is advisable that the EMS officers be offered refresher courses to help them learn proper techniques of documentation. Finally, the problem has been perpetuated for very long it is a high time that experts are to be developed out of physicians in training to have the workforce necessary to a meaningfully turn things around.

Reference

Drees, M., Gerber, J. S., Morgan, D. J., & Lee, G. M. (2016). Research Methods in Healthcare Epidemiology and Antimicrobial Stewardship: Use of Administrative and Surveillance Databases. infection control & hospital epidemiology, 1-10.

Kodankandath, T. V., Shaji, J., Kohn, N., Arora, R., Salamon, E., Libman, R. B., & Katz, J. M. (2016). Poor hypertension control & longer transport times are related to worse outcome in drip-and-ship stroke patients. Journal of Stroke and Cerebrovascular Diseases, 25(8), 1887-1890.

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