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Common Issues in Behavioral Health Documentation and Charting

a person looks stressed while encountering common issues in behavioral health documentation and charting on a computer

Behavioral health practitioners are in the business of helping their patients. Properly meeting their patient’s ongoing needs and coordinating services today is virtually impossible without documenting each patient’s visit, call, point of contact, and encounter in a complete, timely, and accurate manner. However, there can be issues in behavioral health documentation and charting if the records are not complete with all relevant and important facts. Contact Sunwave Health today online or by calling 561.576.6037 to learn about our software tools for behavioral health clinical directors and how they can ensure each of your patients receives the services they need.

What Is Behavioral Health Documentation?

Medical records documentation promotes patient safety, minimizes errors, and improves the quality of care the patient received. It also ensures regulatory and reimbursement compliance. Therefore, medical records should always be maintained in a way that adheres to applicable regulations, accreditation standards, professional practice standards, and legal standards, but Issues in behavioral health documentation arise without the right medical records software.

There has been a mandate for patient information to be stored as electronic medical records (EMRs) since the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009. Various governmental policies regulating patient records and information impose penalties for those not securely storing patient data in an electronic format.

When it comes to staving off potential issues in behavioral health documentation and charting, knowing how to accurately document a patient can be the difference between life and death. Some of the most common issues in behavioral health documentation can also be the most disastrous.

How can you avoid behavioral health documentation errors and provide each patient with appropriate and possibly life-saving care? One way is to use Sunwave software and be cognizant of the issues in behavioral health documentation and charting.

Most Common Types of Behavioral Health Documentation Errors

Creating and maintaining consistent, accurate charts is vital to patient care. Some of the most common errors in documentation include:

  • Illegible handwriting
  • Missing dates, times, and signatures
  • Lack of documentation regarding omitted medications and treatments
  • Incomplete or missing documentation
  • Timeliness of entries
  • Using the wrong abbreviations
  • Entering information into the wrong chart

Sloppy handwriting, for example, should never again come into play when providing care to a patient. This has long been one of the issues in behavioral health documentation and issues in behavioral health charting that can easily be avoided with modern behavioral health software that provides comprehensive solutions spanning the point of care to alumni management. Also, any of the issues listed above can quite easily cause medication errors, which may put the patient at risk. Every day, at least one death in the U.S. happens due to a medication error, and approximately 1.3 million people annually are injured due to medication errors.

According to the Centers for Medicare & Medicaid Services, healthcare providers have been implementing electronic health record software at an increasing rate, and the reasons are crystal clear: to minimize risk by avoiding issues in behavioral health documentation and charting. But there are still hurdles to overcome when using modern software tools.

Issues in Behavioral Health Documentation and Charting

Here are a few issues in behavioral health documentation you may face. Each of these learning issues and barriers can be overcome through education and practice.

Technical Ability

The transmission of behavioral health documentation is only as good as the computers that store and share the records. A computer must have the ability to retrieve and send data, but this may be affected by its age and other factors, such as reliable internet access depending on location.

Buy-In from Key Stakeholders

Unfortunately, not everyone may be comfortable with or ready to implement a digital medical records system. There could be patients and healthcare providers who may easily give up on the software if there’s a lack of understanding or training.

Lack of Customization

The goal of medical record software is to improve workflow, but if it’s not customized to your facility and practice, your efficiency can be impacted. Sunwave is purpose-built for behavioral health. Our single platform integrates everything, and we understand the behavioral health process, from detox to outpatient care. We cover the whole patient journey, and our value-based care emphasizes the quality of treatment.

Learn More at Sunwave

There can be issues in behavioral health documentation and charting, but having the right software partner can eliminate errors and help you provide the best care for your patients. Contact us today 561.576.6037 or online to learn more about our treatment journey solutions, behavioral health EMR system, and comprehensive software platform that is designed exclusively for behavioral health and addiction treatment facilities.