Wrong documentation is mostly inadvertent, but the consequences can be huge. For instance, it was just a typo – an extra ‘0’ – which led to administering a patient 80 units of Levemir insulin instead of the correct dose of 8 units and led to the death of a chronically ill patient. And sometimes it may not be inadvertent but rather a case of incorrect interpretation such as interpreting “210 mg oxycodone,” when it should actually be, “two 10 mg oxycodone.” Just as proper documentation is important for correct treatment, it is also equally important for obtaining full reimbursements, getting accurate quality scores, as well as providing accurate information to patients.  

Medical Billing Documentation Errors

Types of Medical Billing Documentation Errors in 2020 

The three main types of documentation errors committed last year were prescribing errors, transcription errors and administration documentation errors. Prescribing errors are the errors committed on prescribing sheets, such as missing information, wrong date, and so on. Transcription errors occur while transcribing from a prescribing sheet to a patient’s medication list. Administration documentation errors is commonly the wrong documentation of the actual drug dispensation on the medication list. 

Reasons for Medical Billing Documentation Errors in 2020 

During the COVID-19 pandemic most medical billing services were marked increase in documentation errors. Much of the errors can be attributed to unavoidable factors such as acute staff shortages, workarounds and extremely high levels of exhaustion, stress, and burnout. Secondly, documenting in a chaotic and busy healthcare systems with a highly disrupted and redesigned healthcare processes made errors common and recurrent. Lastly, changing regulations on documentation due to pandemic and increased role of telemedicine added to the confusion. 

In a survey carried out by a leading US health journal on 2000 patient records, documentation errors were found in 350. Prescribing errors were found in 35% of them, transcription errors in 50% and administration documentation errors in 15% of them.

Some common issues that led to rampant documentation errors during Covid 19 were 

  • Mishearing drug orders from oral instructions or narrations over phone 
  • Selecting the wrong drug after entering the first few letters of its name 
  • Prescribing daily dosage instead of weekly for several physical conditions 
  • Illegible handwriting that led to wrong entries 
  • Documentation errors made by clinicians 
  • Missing letters in abbreviations such as q.d. instead of q.i.d  i.e. once a day instead of four times a day 
  • Wrong copy-paste in EHR  
  • Scrambled lab results, Incorrect template, misuse of medical word, demographic errors etc. 
Wrong or missing details about date and time were identified in 52 prescriptions (27.6%)

Read Also Benefits of Outsourcing Medical Billing and Coding during COVID-19

Ways to Tackle Documentation Errors In Medical Billing – 2021 

Much of the errors in medical billing services can be tackled by training documentation specialists to refresh their knowledge in a post-covid era. Training needs to be given on the following lines: 

  • Knowledge of relevant medication legislations in the pre-and post covid era 
  • Adequate knowledge of medications specific precautions, contraindications, side effects, adverse effects 
  • Cross check prescription order with prescriber/ pharmacist before medication administration 
  • Determine any known or unknown allergies or adverse drug reactions 
  • Not commit on illegible handwriting, rather cross check with the physician 
  • Checking drug list after the completion of documentation to ensure there is no wrong entry due to auto key in. 
  • Running through abbreviations for a second time. 
 In four cases (3.8%), the prescriptions had no clear dose information. In three cases (2.9%) the instructions were ambiguous that could lead to an overdose 

Why Documentation Technology is a Must

Healthcare providers need to embrace technologies that prompt physicians to document properly and at the same time integrate automatically with the physicians’ workflows. Such technologies can eliminate manual errors like wrong dates, missing fields, etc. For instance, computerized provider order entry assist in designing the correct treatment regimen, provides timely reminders such as including aspirin in coronary artery diseases, controls all the orders with the patient’s problem list etc. Likewise CDSS or Clinical decision support system provides clinical knowledge and related information about a patient, selects and displays information intuitively and at the appropriate time. It helps spot and bypass errors by providing proof-based standards and guidelines; protocols and procedures; and recommendations and rules for care. In today’s age automated intelligence can also be leveraged to analyze medical records to spot missing information and facilitate coding inputs.

In two cases (1.9%), the physician wrote prescriptions but on the wrong patient’s order sheet.

Technology Should Just be an Enabler, Not a Replacer for QA

All said and done, it’s important to look at the documentation leading up to the procedure and after that procedure. In other words, every documentation needs to go through the lens of a documentation quality analyst. And the analyst’s focus should center around the following: 

  1. Does the document logically point to the need for the procedure? 
  2. Was the procedure description adequate and as required by a payer? 
  3. Was the post procedure care described properly? 
  4. Review documents to ensure all secondary diagnoses are covered. 
  5. Identify potential patient safety indicators and hospital-acquired conditions if any 
  In one prescription the frequency of drug administration was missing .  


Reinvent Organizational Strategies 

It is extremely critical for healthcare organizations to establish and promote a safety culture. This means ensuring that all those in charge of documentation feel empowered to speak up, ask questions, seek help, and highlight issues without fear of repercussions. During the covid year the culture took a beat in most healthcare organizations, but with the covid behind healthcare leaders need to do everything to reinstate the culture. While daily huddles can continue, leaders must always be around and communicate clearly about the norms they are supporting. In particular, frequent rounding of documenting personnel and QAs—during which physicians can ask questions and encourage discussions in a supportive way—can inculcate the kind of culture needed to bring preciseness through mutual support. This also means implementing peer support, work hour limits, counseling, and evolving strategies for documentation specialists to minimize stress, fatigue, and anxiety that lead to errors. 


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