EHR Documentation Challenges and Impact on Clinician Burden and Work Hours

Documentation Template Challenges

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.

Patient Identification Errors

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.

Compliance Education

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.

Ensuring Documentation Integrity

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.