Research of Documentation Errors in the Healthcare Profession

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Research of Documentation Errors in the Healthcare Profession

Research of documentation errors in the health care profession is reviewed in this paper. Many people in the medical field believe errors are a result of using abbreviations in handwritten documentation relating to patients. Accreditation agencies are now composing lists of terms that should not be abbreviated in order to reduce these errors. In this research, the following topics will be discussed:

How can eliminating abbreviations reduce error?
Should written policies be developed for abbreviation usage? If yes, what should the policies contain and if no why?
When are abbreviations acceptable, who should use them and why? Have there been enough steps taken to reduce errors?

How can eliminating abbreviations reduce error?
Patient safety is a common goal in every healthcare institution, thus eliminating abbreviations can reduce life-threatening medical errors. The most common is medication errors. Some abbreviations, symbols, and dose designations are frequently misinterpreted and lead to mistakes that result in patient harm. They can also delay the start of therapy and waste time spent in clarification. A nurse administering the wrong dosage to a patient if the physician’s handwritten abbreviations are not clear can be lethal. As well, when a patient is transferred from one care provider to another, if the medical records are written with abbreviations this could lead to tragic results. Thus providing clear, communication, unabbreviated prescribed prescriptions, reports, and records would greatly reduce medical errors. However eliminating all medical abbreviations would reduce errors but if abbreviations were eliminated it would make it very difficult on medical professionals who would have to write out very lengthy medical terms. Since everything in a patient's medical records must be documented, from s/s (signs and symptoms), to the patient's medical hx (history), to the final...
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