January 31, 2022 - Parul Saini, Webmedy Team
In this digital age of healthcare, EHR Documentation is trending as a hot topic today, as it holds numerous benefits for better care coordination. Here we have explained how EHR documentation is important, the basics, benefits, and best practices of EHR documentation.
EHR documentation is often considered as the communication tool used between healthcare providers in documenting patients' health records and making those data easily available and accessible to providers to provide quality healthcare.
EHR documentation tools offer numerous benefits that are intended to improve both the quality and the utility of clinical documentation, enhancing communication between all healthcare providers. These features highlight traditional and notable requirements for documentation standards while supporting new technologies.
Clinical documentation supports patient care, improves clinical outcomes, and enhances interprofessional communication. When you document your assessments, plans, and actions, you rely on nursing practice standards, organizational policies, meaningful use directives, and a variety of quality criteria. Electronic health records (EHRs) support that documentation with data that help you enhance patient safety, evaluate care quality, maximize efficiency, and measure staffing needs.
Documentation templates can play an important role in improving the efficiency of data collection, ensuring all relevant elements are collected in a structured format. However, these templates also have limitations: Templates may not exist for a specific problem or visit type. This issue can occur if the structure of the note is not a good clinical fit and does not accurately reflect the patient's condition and services.
The documentation integrity may get affected when the wrong information is documented on the wrong patient health record. Errors in patient identification can affect clinical decision-making and patient safety, impact a patient's privacy and security, and result in duplicate testing and increased costs to patients, providers, and payers.
Organizations must have a patient identity integrity program that includes performance improvement measurements that monitor the percentage of error rates and duplicate records within their electronic master patient index.
Healthcare organizations must spend some time to ensure providers are well-informed about compliance and legal risks. How it can be achieved? – Via EHR training process. Organizations may need to develop initiatives in EHR education to make sure they do not risk compliance problems. Staff education on best practices for documentation should focus mainly on the integrity of the health record.
Documentation integrity includes the accuracy of the complete health record. It envelops data administration, patient identification, understanding recognizable proof, origin, and record corrections as well as auditing the record for documentation validity when submitting reimbursement claims.
EHRs have customizable documentation applications that permit the utilization of templates to help with documentation. Unless these EHR implementation tools are used correctly, the integrity of the data may be questioned and even perceived as fraudulent activity. So to resolve this, the healthcare providers must understand the importance of reviewing and editing all defaulted data to ensure that only patient-specific data for that visit is recorded, while all other irrelevant data pulled in by the default template is taken out.
With the increased adoption rate of electronic health records (EHRs), there is also a concern that a potential loss of documentation integrity could lead to compromised patient care, care coordination, as well as fraud, and abuse. So these best practices for quality EHR documentation guide you for maintaining documentation integrity while using automated EHR functions.