Documentation Errors and Deficiencies in Medical Records: A Systematic Review

Abstract

Introduction Identifying errors in documentation can improve the quality of medical records, healthcare services and health care systems, and thus provide a good framework for improvements in documentation policies. To this end, the current research systematically examined studies reporting documentation errors and deficiencies in medical records. Method The systematic review was conducted based on PRISMA. Original articles, published in English from January 2009 to April 2019, were retrieved using the Web of Science, Scopus, EMBASE, PubMed and Google Scholar. Results A total of 7,624 articles were found. After the exclusion of duplicates and irrelevant items from this total, just 48 articles met the requirements of the study, among which 47 had some sorts of incompleteness; inaccuracy, 14 articles; inconsistency, 8 articles; illegibility, 7 articles; unsigned document, 4 articles and irrelevancy, 2 articles. Factors contributing to the incidence of documentation errors included occupational stressors, manual documentation and absence of or a defect in local, national and international standards or guidelines, with 12, 9 and 11 articles, respectively. Discussion Incompleteness, inaccuracy and inconsistency are common errors in medical records documentation. Adopting necessary policies for enhancing the quality of documentation, making strides towards electronic documentation equipped with automatic error detection systems, and standardising the documentation process can be of great assistance in minimising documentation errors and deficiencies.