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Common Charting Errors

When charting in a medical office, there are some key things to look out for:
Course

Introduction to Psychology (PSYC 1010 )

57 Documents
Students shared 57 documents in this course
Academic year: 2022/2023
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This document has been uploaded by a student, just like you, who decided to remain anonymous.
Metropolitan Community College, Nebraska

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Common Charting Errors

As a scribe your charting is expected to be error free; you should strive to achieve this goal during your training. Therefore, during training it is important to review and correct your charts. By categorizing the types of errors found on each chart you can focus on the most significant areas for improvement. Below are the most common types of errors, ranked in degree of severity.

  1. Contradictions: Internally inconsistent documentation.

  2. Listening Errors: Factual inaccuracies, often misheard, misunderstood, or fabricated entirely. This includes inappropriately used medical terms.

  3. Incompleteness: Missing information.

  4. Mischaracterization: The charting may be factual, but the facts are misrepresented or poorly described to the point of inaccuracy.

  5. Poor Grammar or Spelling: Misspellings or poor sentence structure obscures the clarity of the chart.

Common strategies for improvement

● Read and re-read every chart. Review it word-for-word, line-by-line to look for errors

● Taking notes

● Focus on the physician/patient conversation rather than the documentation system.

● Check spelling with Google or reference materials.

● Re-read sentences for clarity.

Was this document helpful?

Common Charting Errors

Course: Introduction to Psychology (PSYC 1010 )

57 Documents
Students shared 57 documents in this course

University: Metropolitan Community College, Nebraska

Was this document helpful?
Common Charting Errors
As a scribe your charting is expected to be error free; you should strive to achieve this goal during
your training. Therefore, during training it is important to review and correct your charts. By
categorizing the types of errors found on each chart you can focus on the most significant areas for
improvement. Below are the most common types of errors, ranked in degree of severity.
1. Contradictions: Internally inconsistent documentation.
2. Listening Errors: Factual inaccuracies, often misheard, misunderstood, or fabricated
entirely. This includes inappropriately used medical terms.
3. Incompleteness: Missing information.
4. Mischaracterization: The charting may be factual, but the facts are misrepresented or
poorly described to the point of inaccuracy.
5. Poor Grammar or Spelling: Misspellings or poor sentence structure obscures the clarity of
the chart.
Common strategies for improvement
●Read and re-read every chart. Review it word-for-word, line-by-line to look for errors
●Taking notes
●Focus on the physician/patient conversation rather than the documentation system.
●Check spelling with Google or reference materials.
●Re-read sentences for clarity.

Students also viewed

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