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Incomplete Medical Charts: Impacts And Possible Solutions

Published online by Cambridge University Press:  01 September 2022

M. Chowdhury ,
S. Peteru ,
A. Askandaryan ,
D. Banik  and
J. Hiana
M. Chowdhury*
Affiliation:
JAMAICA HOSPITAL MEDICAL CENTER, Psychiatry, NEW YORK, United States of America
S. Peteru
Affiliation:
JAMAICA HOSPITAL MEDICAL CENTER, Psychiatry, NEW YORK, United States of America
A. Askandaryan
Affiliation:
JAMAICA HOSPITAL MEDICAL CENTER, Psychiatry, NEW YORK, United States of America
D. Banik
Affiliation:
ST. JOHN’S EPISCOPAL HOSPITAL, Psychiatry, FAR ROCKAWAY, United States of America
J. Hiana
Affiliation:
SUNY DOWNSTATE MEDICAL CENTER, Neurology, BROOKLYN, United States of America
*
*Corresponding author.

Abstract

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Introduction

Proper documentation and relevant updating of patients’ health status has become a cumbersome task with the inception of electronic medical records.Inpatient, ED, and ambulatory patient evaluation generate billions of records each year.It brings about a burden on the workload of the providers regarding registering and completing patients’ records.Incomplete medical records set up complications in patient management and subsequent administrative operations.Specifically, denials for reimbursement because of incomplete medical records emerge as a critical concern.Effective measures, consisting of both technical and administrative enforcements are required to reduce number of open charts.

Objectives

To understand the reasons,consequences and solutions for Incomplete/Delinquent medical records.

Methods

We searched Google scholar and Pubmed database using keywords “Incomplete medical records”, “Imapacts” and “Solutions”.Articles popped up.We selected 4 based on internal and external validity.

Results

Incomplete/Delinquent medical records are nowadays imposing a critical challenge upon financial, administrative and legal affairs in practicing Medicine.Our review shows that CMS recovery audit with hospital denials went high from 7-10% in recent years because of open/incomplete medical records.Provider’s documentation time increases as well with implementation of EHR.Appropriate measures could be taken to resolve this issue, broadly we can try two ways- training and administrative courses.

Conclusions

Physicians,residents and all respective providers should get training on a regular basis regarding EMR/EHR to complete medical records duly and effectively.The other way is administrative surveillance.If providers fail repeatedly to comply with HIM standard and complete delinquent medical records, warnings, suspensions or other regulatory actions can be executed strictly to keep them on track.

Disclosure

No significant relationships.

Keywords

SolutionsIncomplete ChartsImpacts
Type
Abstract
Information
European Psychiatry , Volume 65 , Special Issue S1: Abstracts of the 30th European Congress of Psychiatry , June 2022 , pp. S747
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
© The Author(s), 2022. Published by Cambridge University Press on behalf of the European Psychiatric Association
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