Record Keeping and Maintaining a Professional License

Deficient Record Keeping

In every single profession and industry, paperwork and records are a given. Records reflect business’ financials, patients they treat, medications given, give instructions for another professional to work off of, instructions for projects, and so much more. Without record keeping and properly maintaining documents, most businesses can suffer from disorganization, poor care for clients and patients, inadequate work, and a damaged reputation. Properly maintaining records is essential for keeping clients and other information organized so the business can move forward, rather than having to deal with problems that arise due to disorganization. 

Issues in the Healthcare Industry

There are some major problems that can arise when healthcare professionals do not maintain proper records. One of these problems is that poor patient records or gaps in record could cause other healthcare professionals to make mistakes in the future. Patient records cannot be incomplete because patients could receive the wrong care or medications. Missing gaps in records make an investigation even worse because missing gaps reflect poor medical care or can support allegations of fraud or negligence. Some other problems for all businesses include: 

  • Wasted time and efficiency is a result of poor record management because there is more time spent with client interactions, dealing with billing problems, checking records, and trying to locate records. Dealing with poor records takes away from time that could be spent on marketing, sales, and services. 
  • Reputation damage is a result of poor record keeping because it gives off the appearance to patients and clients that the business or the professional is sloppy and careless when it comes to their care and service. Word can spread quickly when careless mistakes lead to harmful results for patients and clients. 
  • Clutter and disorganization can cause the office or the business to look dysfunctional and sloppy and even make patients and clients feel overwhelmed. Even the appearance of this could make people feel uneasy and want to look elsewhere for their care or services. 

Common Errors

In healthcare, many physicians, nurses, and counselors must work in a very high-paced environment and quickly handwrite patient records. Even poor handwriting can lead to poor record keeping. Transcription mistakes like typing “hyper” instead of “hypo” or even “he” instead of “she” could lead to coding errors and other staff errors. Other problems could be pulling the wrong file altogether which could cause many errors for treatment and patient care. Many businesses and facilities have decided to go electronic when it comes to client and patient records because it makes transcription mistakes much less likely. Electronic records also allow for duplicates and backup plans. 

Some ways to prevent poor record keeping in the future are putting a plan in place, such as protocol for paper records, storing data, and possibly switching to an electronic recording system. Organizing documents often can make a business much more efficient and make it less likely to make mistakes because of losing records or mixing up client information. Having backup plans and disaster recovery plans can allow professionals to ensure that lost information will not require them to start over and have documents necessary if there is an investigation. 

Getting Help

Poor record keeping can cause professionals to contribute to inaccurate care, cause others to make mistakes, lead to inappropriate billing, cost loss of revenue, damage the professionals reputation, and ultimately lead to a loss of license. If you feel that your professional license is in jeopardy because of poor record keeping, call our office to speak with an attorney who can give you more information. 

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