Over the course of the last two decades, the medical industry has greatly evolved, and the demand for integrated and convenient medical documentation has been increasing to improve the efficiency and productivity of healthcare services for both patients and physicians. The impact of electronic health records is pretty effective, but there are also various challenges in implementing electronic health records.
Electronic health records have improved the monitoring of patient care while minimizing the risk of errors during the treatment process. With the ever-changing technological standards, it’s essential to understand the documentation process and why it has become a crucial part of the medical industry. That being said, below we will be sharing the importance of proper medical documentation in the EHRs!
Standards and Guidelines Pertaining To Health Records
“Why is documentation important in healthcare?” is a widely asked question, but understanding the standards and guidelines pertaining to health records is even more important. To begin with, the health records must have the patients’ ID number and name on every page. As for the patients’ biodata, it must include the contact number, employer, address, and marital status.
The entries in medical and health records should have identification, such as electronic initials, identifiers, and handwritten signatures. As far as the entrees are concerned, they must be dated. The health records have the problem list, which must include the medical conditions or illnesses of the patients. On top of everything, the potential adverse reactions or medication allergies must be outlined.
One might believe that only the current medical information of patients is essential, but the health records also need to include the past medical history, inclusive of severe illnesses, conditions, and accidents. In the case of younger patients, the medical history needs to include the illnesses and operations of childhood, along with prenatal care.
One most essential guideline is adding information about the use of substances and alcohol in patients. With the medical health records, the lab tests must be ordered, along with diagnoses for outlining the findings. With health records, the physicians have to ensure that treatment plans are complying with the diagnoses, along with follow-up care and visits.
The health records must outline the unresolved issues through medical treatments. In case patients request a consultation, the note from the consultant must be added to the records. All the lab reports, imaging reports, and consultation reports must be initialed by the physician before it’s added to the health records. Also, the immunization records of young patients must be updated.
Medical Record Documentation – Best Practices
Electronic health records and documentation can be complicated, and it wouldn’t be wrong to say that doctors are still trying to adapt to the change. To begin with, the physicians must have a clear understanding of the scope and best practices for maintaining medical record documentation. Certain best practices can assist physicians to keep up with the right medical record documentation.
These practices are essential for the proper exchange of information during interactions between patients and physicians. In addition, it ensures that all the interactions are properly recorded and are integrated with the notes. These practices involve ensuring that health records have accurate and precise information. Also, the patients must encourage routine analysis of healthcare records.
The medical staff must ensure that health record documentation is part of competencies. The healthcare facilities must implement the six Cs with medical record documentation which includes the cause of disease symptoms, clinical importance of the negative test results, chronic conditions that can influence patient care.
In addition, six Cs also include clarity and checking the laterality. The documentation review must be conducted properly, ensuring that everyone is able to understand the knowledge gaps. The physicians must collaborate with each other to create practical and measurable goals for improving the documentation.
What Is The Primary Purpose Of EHRs For Proper Medical Documentation?
The electronic health record is the digitalized paper chart of the patients. These solutions are real-time and are focused on patients for instant availability of the information. In addition, it promises secure storage of data and information for authorized users.
The primary purpose of EHR in proper medical documentation is its ability to contain the treatment plans, diagnoses, medical history, medications, allergies, immunization dates, lab test results, and radiology images. It allows access to tools that physicians can use for making decisions regarding patient care and treatment plans.
The implementation of EHRs can help streamline and monitor the healthcare workflow processes. With proper adherence to the medical record documentation standards, the healthcare facilities will be able to create the information and manage them in a digital form. In addition, even the affordable care act and electronic health records help with information sharing across different facilities and organizations.
It’s already a fact that EHRs are seamlessly replacing the paper-based patient charts with electrical and digital patient charts. It can be utilized for producing electronic notes without compromising on efficiency and effectiveness. With EHRs, the clinical notes can be easily entered that align with the documentation and evaluation standards.
Best Tips for Medical Documentation with the Help of EHRs
The medical documentation process is incredibly important (equally important to the patient interactions). With accurate notes and reports, the communication about care continuity and practices is improved. Also, it reduces the chances of queries and enhances the claim reimbursements. This is one of the prime reasons that organizations have invested in automated solutions.
These automated solutions allow the physicians to improve the clinical notes. However, some tips can improve the outcome and effectiveness of the medical record and documentation, such as;
- Identifying the Professional Standards
To improve the medical documentation, professional standards and guidelines must be outlined that comply with the industry standards. These standards must have brevity and clarity.
- Education & Awareness
It’s evident that some healthcare facilities think that new recruits will be aware of CMS medical record documentation guidelines and standards, but these skills can be improved. It’s suggested to create a well-integrated and structured awareness and training campaign. The training must be offered about medical documentation to new as well as current employees.
- Support Systems
In particular, we are talking about peer-to-peer support systems. For reducing the dependence on EHR vendors, nominating the personnel for heading the documentation improvement will be a better choice. The personnel must be aware of the ins and outs of top documentation practices.
- Reviewing the Information
This is the most important yet the most underrated part of the documentation process. Everyone must review the documentation system because it’s beneficial for improving the accuracy of electronic health records. All in all, the small errors can be identified, corrected, and validated.
Electronic Medical Records Policy and Procedure Template in EHRs
- Declaration of Legal Health Records
When it comes down to the electronic medical records policy and procedure for EHRs, there are specific elements that are often mentioned in the medical documentation template. In the first place, the legal health records must be declared. It includes the source of clinical data, clinical records, external reports, and records.
- Completion Of Documents
The documents must be optimized and completed. There are paper as well as electronic portions to consider when it comes down to the documents. It’s essential to localize the electronic documents and ensuring that the documents are only available in the read-only form.
- Amendments & Corrections
The policy and procedure template in the electronic health records must include amendments and corrections. The changes are made in the form of amendments, deletions, and addendums. However, the changes are not limited to the back-end programs. As far as the changes are concerned, it must have the feature to change the account number, medical record number, patient name, service data, and signature.
- Authentication, Dating, And Timing
The authentication and timing must be consistent and comply with federal and state laws. All the entries and data in the medical records must be authenticated, dated, and timed in the electrical as well as written form. This must be done by the person who is responsible for providing the provided services. Also, all the information and entries must be documented accurately.
When it comes down to the versioning in medical record documentation, the healthcare facilities have to check if different versions of the document will be displayed or only the final version. In addition, it outlines who will have access to the document version, and the flagging must be outlined for every version and their availability.
- Records Of Outpatients
The healthcare facilities have to maintain the record of every patient who is receiving outpatient services. This record must be correlated and maintained according to the medical records from emergency and inpatients.
The healthcare facilities should work in collaboration with the legal and information services for creating and maintaining the documents. The content needed for decision-making must be identified. Also, all the information content should be developed, coordinated, and administered.
- Maintenance & Revision
The legal health record policy and procedures must be revised after an in-depth review. The review must be done on an annual basis. Also, it ensures that information is updated and in compliance with current data.
Medical Record Documentation and Legal Aspects Using EHRs
- Malpractice Claims in Medicine
The EHRs surely show better performance and long-term benefits. However, there are some errors associated with the implementation process or transiting from manual to digital system. That being said, it can result in malpractices and errors, which subsequently lead to penalties, and fines for hospitals, and other healthcare institutions.
- Medical Errors
It’s usually believed that EHRs can reduce the chances of medical errors. However, extra dependence and complacency on these systems can result in minor mistakes that can result in colossal medical errors.
- Unauthorized Access
With the higher utilization of technology, there are rising threats to cybersecurity breaches. The computerized system is always prone to unauthorized access by hackers, hence higher chances of data theft. That being said, unauthorized access can lead to strict legal actions against hospitals, and healthcare facilities.
Medical Record Documentation Examples Which Fit In Electronic Medical Records
When it comes down to electronic medical records, the medical record documentation has various factors involved, such as billing data, administrative data, demographics of patients, progress notes, medical histories, and vital signs. In addition, it outlines the medications, diagnoses, allergies, immunization date, and radiology images.
Impact of Electronic Health Records on Healthcare Documentation Specialist Roles and Responsibilities
To begin with, the impact goes beyond the prescription of medications. According to early research, electronic records can enhance preventive care through different conditions. In addition, these systems have improved the cardiovascular conditions within the primary care niche. These documentation systems can be utilized for implementing the care guidelines.
These systems can improve the management and communication of the clinical information for patients as well and healthcare providers. In addition, these systems help to minimize the errors in prescriptions. Also, the complex orders can be clarified and help with improved and quicker access to the health information and data.
What is one of the purposes of medical documentation?
The precise and clear documentation is essential for providing quality care to patients while ensuring timely payments. On top of everything, the medical documentation will empower the healthcare providers to plan the treatment, thus improving the overall quality of healthcare services.
Which principle should guide the nurse’s documentation of entries on the client’s medical record?
When it concerns the principles for guiding the documentation entries, precise measurements must be used instead of approximate values.
What are some ways to reduce medical errors in documentation?
For reducing the medical errors in documentation, the procedures must be double or triple-checked. In addition, using the name alerts and following the correct reconciliation processes is essential. Lastly, everything must be documented properly.
Why are accurate medical coding, billing, and documentation important?
It can lead to on-time payment claims for physicians and hospitals. In addition, accurate documentation will result in effective and better patient care services.
What is a medical documentation specialist?
The medical documentation specialist is responsible for listening to the physicians’ voice records. Also, they transcribe the information in the electronic records and reviews.
How is the documentation organized in the patient’s medical record?
The documentation is organized in the patient medical records in the categories of vital signs, demographics, medications, problems, allergies, progress notes, and treatment plans. It can be recorded on online systems
What is a healthcare documentation specialist?
The healthcare documentation specialist is responsible for creating the medical records of the patients and revising different aspects of the patient’s health and medications.