Serious problems can result from incomplete or missing charts. For example:
- Patient care is compromised. Quality of care decreases when nurses or physicians cannot answer a patient's question quickly, or must delay treatment because they cannot review lab results.
- Liability increases when charts are not available for use when patients call or come into the office for care.
- Patient trust is eroded when patients must wait to see the doctor, or when they cannot get timely answers to medical questions.
- The practice bottom line suffers when payroll expenses increase because office staff spend too much time looking for missing charts, or documentation is not readily available for use in claims processing.
TMA Practice Consulting suggests you take these steps to solve the problem:
- Identify all processes in your office that produce a missing chart situation.
- Solicit ideas from staff and physicians for solutions and new processes to eliminate the problem.
- Design a protocol with the new processes.
- Train all staff and physicians on the new protocol, and include the protocol in your policies and procedures manual.
- Require compliance with the new protocol, and develop appropriate consequences for noncompliance.
By improving your chart system, quality of care increases, patients' perception of your practice improves, liability risk decreases, and you should realize a positive impact to your bottom line.
Content reviewed: 2/23/07
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