Documentation in medical record is the basis for communication between health professionals which inform the care provided, the treatment rendered, care planned and the outcome of that care as a continuous and existing record. Health information documentation is a document about healthcare services that is provided to an individual patient. If documentation doesn’t give a clear presentation of a patient’s history, it is termed improper documentation. Thus, this study aims to determine the level of patient documentation practice and ascertained the technical knowledge possessed by health record staff practicing documentation
A descriptive research design was used and a convenient sampling technique was employed to administer questionnaire to health records staff in University College Hospital. A total of 150 participants were used and 114 questionnaires were retrieved. The data collected were analyzed using frequency table and simple percentages, with the aid of statistical package for social sciences [SPSS] version 16..
It was discovered that majority of the respondents 87[76.3%] have adequate knowledge about documentation and almost all 113[99.1%] of the respondents said training is required for proper documentation. Findings revealed that factors that contribute to improper documentation include lack of time to document patient care, insufficient staff, illegibility of handwriting, lack of interest, lack of conducive working environment, inadequate knowledge concerning the importance of documentation and shortage of materials for documentation. Results of improper documentation include patient death, litigation cases and complications in patient health.
Finally, this study has showed clearly the impact of improper documentation among health records staff, which facilitates diagnosis and treatment, communicates pertinent information to the other caregivers to ensure patient safety, reduce medical error and serves as an important medico-legal function in risk management. In conclusion, based on this findings management should conduct periodic training and re-training of healthcare professionals to improve documentation for effective documentation process and government should provide the health records staff with the required needed materials to document accurately.
CHAPTER ONE
INTRODUCTION
1.1 Background to the studyAccording to Paul and Thomas [2013] Documentation is vital to safe, ethical, and effectivenursing practice in clinical areas. Nursing practice requires documentation to ensure continuityof care, planning, and accountability, as well as in the promotion and uptake of evidence-basedpractice, documentation provides a method of evaluating the quality system performance of thesupplier to sense the provider of quality material and product is selected. In acuminate careoperation or treatment, it is critical to document each patient condition and history of care, toensure the patient receives the adequate health care, the information must be passed through allthe health professionals of the care giver, adequate documentation is always important in a healthcare setting. Albaelak, [2010].Documentation is a necessary component of safe, ethical and effective medical practice. Healthprofessional are required to document and keep records of their professional practice inaccordance with standard of practice, and organizational policies and procedures. As healthprofessional, the health and care of patient is of greatest concerns, and it is clear that inadequateclinical documentation impact on both patient care and outcomes. For instance, a family doctortreating a patient without the benefit of a discharge summary from an acute care, physician isworking at a disadvantage in a potentially life-threatening situation. Therefore, quality physiciandocumentation shared in a timely manner can be of help to avoid negative consequences, such asadverse medication events. Martin, [2012]. According to Malcoh [2012], documentation can bedefined as a clear concise and accurate history of the patient’s life and illness written from themedical point of view. He went further to say that before the records can be completed, it mustcontain sufficient data written in sequence of event to justify the diagnosis and warrant thetreatment and the end result.
While doctors and other healthcare professionals are obligated to act in the best interests of their patients, things don’t go perfectly all the time. Any incorrect, missed or delayed diagnosis can have life-altering impacts that can be devastating to the patient and their family. In addition to the complexity and difficulty that comes with pursuing a medical malpractice claim, it can also be incredibly draining on your financial and mental wellbeing.
In general, a medical malpractice claim takes place when there is a breach in the duty of care to the patient or some form of negligence occurs, such as an error in medical records which can have serious consequences resulting in injury or in worst cases, death.
Unfortunately, these errors in medical records are not uncommon and almost 1 in 10 people who get a hold of their medical records often need to ask that they be fixed for any number of reasons. Some common examples of errors that can have adverse impacts on a patient’s health include:
- Transcription errors;
- Omissions from medical records;
- Incorrect information [ex. A diagnosis, scan or lab result] being placed in a patient’s file;
- Inadequate information on patient history;
- Wrong or inadequate information regarding medications or allergies.
Due to these errors in medical records, you might suffer injury or even death. The following are reasons why you may be able to sue for incorrect medical records, which could potentially lead to a successful medical malpractice case in Canada.
1. Cause of Death
In Canada, medical errors account for up to 28,000 deaths each year according to the Canadian Patient Safety Institute. It is the third leading cause of death in Canada next to cancer and heart disease. These deaths occur because of minor, moderate or severe errors. In addition, medical record errors can injure or cause a worsening of the illness for the patient. In these cases, it is of the utmost importance to catch these mistakes before they can cause significant damage.
2. Incorrect Medication
If your doctor or hospital staff make an error in your medical records regarding medication, it may lead to incorrect drug or dosage administration. In most cases, this does not result in a reaction from the patient but in some cases, it will have adverse effects that may lead to injury or death. Errors in dosages can cause seizures, internal damage and long-term or permanent injuries.
3. Unnecessary Treatment or Surgery
An error in medical records might result in incorrect, unnecessary or detrimental treatment options or surgery. This can shorten the life of the patient or cause them harm. This occurrence can be used as strong evidence during a medical malpractice lawsuit against the hospital in comparison instead of a single professional. Accurate records are vital to ensuring the health of a patient and the hospital or medical facility may remain responsible for any inaccuracies or mistakes made.
4. Negligence of the Health Professional
The health professional assigned to your case can engage in negligent behaviour through lack of attention, lack of care or reckless or careless activity which can result in the recording of incorrect or inaccurate details in your medical record. Even if this medical professional does not make an error during this instance, there is no guarantee that it won’t happen in subsequent treatments or future procedures which can cause injury.
5. Injury
If your medical error leads to misdiagnosis, wrong treatment or incorrect medication or dosages, the resulting injuries are usually quite severe. Not getting the right procedure or getting the wrong surgery can cause serious damage or even lead to the patient’s death because something vital is not provided or it was performed incorrectly. The longer this goes on, and if there are more negligence issues in treatment or breach of duty of care, then this will increase the harm done to a patient. Issues that arise through medical errors can require a lawsuit so the victim can recover both financially and ensure that they get the correct treatment no matter what it is or how much it costs.
Pursuing a medical malpractice claim can be one of the most complex and difficult legal cases. Nonetheless, if the error found in your medical record is obvious and severe, the strength of your claim may increase considerably. It is important to consult with an experienced and accredited attorney and provide them with all of the details, evidence and records necessary to support your claim in the courtroom.
Sommers Roth & Elmaleh is one of the oldest and most established medical malpractice firms in Toronto. Our firm has more than 40 years of experience representing victims affected by medical misdiagnosis and medical negligence. We are extremely knowledgeable in helping our clients navigate the medical-legal system and we have many successful medical malpractice cases in Canada under our belt.
Consult a Medical Malpractice Lawyer in Canada Today
The expert lawyers and Sommers Roth & Elmaleh have helped Canadian patients win their medical malpractice claims for decades. We have fought and won a substantial number of serious medical litigation cases. Our seasoned and experienced medical malpractice lawyers work with top-tier medical professionals across the country.
To learn more about medical malpractice, call Sommers Roth & Elmaleh at 416-961-1211 or contact us here.
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