Electronic Documentation
October 11, 2022
Reading time: 3 minutes
Accurate and thorough documentation is the backbone of a sound approach to risk management; it provides essential patient information, historical details about the course of patient care, and a record of services provided.
Electronic health records (EHRs) have not diminished the importance of documentation, but they have fundamentally changed the process of documenting patient care, resulting in new documentation risks. To address these challenges, healthcare practices need policies and strategies that reinforce EHR best practices. Use this checklist to review important risk management strategies for electronic documentation and identify potential areas for improvement.
| Yes | No | |
|---|---|---|
| Does your practice have written documentation policies that include standards and guidance specific to electronic documentation? | ||
| Do documentation policies support and enforce a consistent approach to electronic documentation among healthcare providers and staff members? | ||
| Do documentation policies include information related to copying/pasting, or ”cloning,” data in EHRs? Does guidance specifically outline when copying/ pasting is prohibited and when it can be used with extreme care? | ||
| Are healthcare providers required to carefully review and sign off on any copied/pasted information in EHRs? | ||
| Are EHR entries periodically audited to check for errors that may have resulted from copying/pasting information? | ||
| Are providers required at each patient encounter to review EHR data fields that default to ”normal” to ensure clinical data are not misrepresented? | ||
| Are providers encouraged to perform a final quality assurance review of all data entered into data fields and check boxes? | ||
| In addition to using data entry fields and check boxes, are providers encouraged to enter patient-specific notes and comments in EHRs as appropriate? | ||
| Have documentation polices related to amending or altering records been updated to reflect EHRs? Do these policies explain how to appropriately amend a record and offer guidance for when alteration is prohibited? | ||
| Has your practice adjusted its documentation policies to account for potential issues that metadata might present, including issues related to the timing of care and amendments to records? | ||
| Do organizational and documentation policies include guidance and requirements for the use of scribes (if applicable)? | ||
| Are records periodically printed out to ensure that print versions are logical and accurately reflect patient care? | ||
| Are healthcare providers and staff members educated about: | ||
| · The EHR system used at the practice, including its functionality, capabilities, and any nonstandard features or modifications? | ||
| · The practice’s general and electronic documentation policies? | ||
| · The risks and consequences of EHR documentation shortcuts, such as misinformed treatment decisions and fraudulent billing allegations? | ||
| · The concept of metadata, how the EHR system collects metadata, and what types of data are collected? | ||
| · State and federal laws or rules related to e-discovery? | ||
| Does EHR training occur during orientation, as part of in-service training, when policies change, and when new technology is implemented? |
Resources
- Checklist: Documentation Essentials (MedPro Group)
- Checklist: Improving Patient Identification and Matching in Electronic Health Records
(MedPro Group) - Data Insight: Claims Involving Issues Related to Electronic Health Records (MedPro Group)
- EHR Copy and Paste and Patient Safety (Agency for Healthcare Research and Quality)
- Electronic Health Records: Patient Safety and Liability Concerns (MedPro Group)
- Guide to Reducing Unintended Consequences of Electronic Health Records (HealthIT.gov)
- Patient Safety Primer: Electronic Health Records (Agency for Healthcare Research and Quality)
- Risk Tips: Using Scribes to Document Clinical Care (MedPro Group)
- Tips for Amending Electronic Health Records (MedPro Group)
- Unintended Consequences: Identifying and Mitigating Unanticipated Issues in EHR Use (American Health Information Management Association)
- Using an EHR as a Quality Improvement Tool in Your Healthcare Practice (MedPro Group)
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This document should not be construed as medical or legal advice and should not be construed as rules or establishing a standard of care. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.
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