Using EHR documentation to improve clinical data integrity

Using EHR documentation to improve clinical data integrity

Technology has improved both the speed and the convenience of medical record documentation. Electronic health records (EHR) that keep a patient’s data organized and accessible have virtually eliminated the need for traditional paperwork in an independent physician’s office. However, an unbalanced emphasis on speed and efficiency can also lead to input errors. When optimizing the use of EHR documentation, care must also be taken to maintain the integrity of the data.

Data integrity is crucial to ensuring that patient records are accurate, so patients receive the appropriate care. Otherwise, decisions might be made based on erroneous information, leading to potentially disastrous results. Data integrity is also crucial for meeting reimbursement requirements.

The American Health Information Management Association (AHIMA) published a 2013 update to its EHR Documentation Guidelines, Integrity of the Healthcare Record: Best Practices for EHR Documentation. Their update includes the guidance for providers completing patient records that they “must recognize each encounter as a standalone record, and ensure the documentation within that encounter reflects the level of service actually provided and meets payer requirements for appropriate reimbursement.”

Relying too heavily on tools of convenience within the electronic record platform, such as “copy and paste” and automatic fill-ins can lead to compromised data. Providers and their staff must understand the necessity of reviewing and confirming that information in the patient chart is accurate, before relying on it for the patient’s healthcare plan or submitting for reimbursement.

Maintaining accurate documentation within the EHR is essential for the health of the patient as well as for the health of the independent provider’s practice. Data that contains errors, such as another patient’s information, can not only endanger those patients but also can become an HIPAA issue if not handled appropriately. A few minutes spent on verifying data can help ensure that the patient is being treated accurately and that the practice is on solid ground for reimbursement and records integrity.