Guidelines for Accurate EHR Documentation
EHR implementation and use can be speeded up with the support of medical transcription services.
MEDICAL TRANSCRIPTION SERVICE COMPANY 8596 E. 101st Street, Suite H Tulsa, OK 74133 Phone : 1-800-670-2809
EHR is an electronic record of an individual’s medical history and the use of this standardized system enables secure exchange of health information, helps improve healthcare quality and patient safety, and reduces health costs. EHR implementation and use can be speeded up with the support of medical transcription services. Traditionally physicians dictate into a preferred recording device and the medical transcriptionist transcribes these recordings into text format. But today, with EHR and speech recognition technology, the role of medical transcriptionists has changed; they function more in the capacity of medical language specialists. Medical transcriptionists edit the transcript provided by the software and ensure maximum accuracy. EHR-integrated medical transcription via HL7 interface is a great option healthcare organizations and providers can utilize to ensure compliance and accurate documentation as well as timely reimbursement from insurers. EHR implementation comes with an increasing concern regarding loss of documentation integrity. This is a serious issue because it could result in patient care, research and quality reporting being compromised. It also poses the risk of fraud and abuse. Factors that Have an Impact on EHR Documentation Integrity If documentation is to be reliable, it has to be accurate. Accuracy of the health record is important with regard to patient identification, provider details, information governance, amendments and record corrections made. Moreover, accuracy is important also when submitting reimbursement claims to payers. Healthcare providers and transcriptionists should review and edit the health record to ensure that only relevant and patient related data is recorded and that it is accurate. Physicians should consider every patient encounter seriously to provide top level service, to meet patient requirements and for quick and accurate reimbursement. All health information such as lab results, medication changes, chronic health conditions and so on must be included. EHR Documentation – Legal Concerns EHR is expected to ensure patient safety, quality care and compliance. Therefore documentation practices should be state-of-the-art. Erratic documentation can lead to medical liability. Following are some of the challenges associated with EHR systems. 
Problematic Templates o
Templates do not allow detailed documentation and this makes it difficult to document multiple health concerns patients may have, as well as extensive interventions.
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Sometimes, a template may not be available for a particular problem or visit type. This makes it difficult to accurately signify the patient’s condition and medical services provided.
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Templates designed to meet reimbursement norms may not allow detailed documentation of clinical information. Sometimes, these may even encourage over-documentation to meet reimbursement criteria even in cases where services provided are not medically necessary or are never delivered.
Dictation Errors Using voice recognition without a validation step can lead to serious medical record documentation problems and errors, with the quality of data being severely compromised. Healthcare units have to implement systems to ensure that providers edit, review and approve the dictated details in a timely manner. Properly documented EHR provides accurate patient information and enables a systematic workflow.
The Copy - Paste Issue Another practice that can cause errors in EHR is cloning or copy-paste. EHRs are designed in such a way that they facilitate cloning or copy-paste to replicate the information. But this method involves many risks and can result in inaccurate documentation. o
Vital signs of the patient may change from visit to visit and these may not be recorded.
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A patient’s health information may be mistakenly copied and pasted from another patient’s record.
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Use of identical verbiage repeatedly for all patients a provider sees within a specific timeframe with practically no modifications, not considering the presenting problem or intensity of service.
Errors in Patient’s Identification Entering wrong patient details into the health record can compromise documentation integrity. Such errors can have a negative impact on clinical
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decision making as well as patient safety. It may also create other issues such as duplicate testing and increased costs to patients, providers and payers.
Issues Related to Provider Identification If the contributors to a healthcare record are not individually identified, it can create confusion as to who administered the care as well as the time the care was provided. EHRs that don’t have the functionality to enable multiple providers to document and sign, verifying the actual service provider and the amount of work performed by each may become impossible.
Inability to Include Amendments Legal issues can arise with EHRs that don’t allow providers to make additions, corrections, and deletions in the record.
Lack of Adequate Audit Trail Functionality If EHRs lack audit trail functionality, it may put the organization at risk of inadvertently protecting or making criminal activity. There will be no way to find out if and when corrections or changes were made to the health record, who made the changes, or the nature of the changes.
Considerations for Maintaining Health Record Integrity
Commitment and desire to conduct business and provide care in an ethical manner
Buying systems that have the capabilities and functions to prevent fraudulent activities
Implementing and using strict policies, procedures and systems that can help prevent malpractice in the healthcare units
Appointing HIM professionals, IT design experts and implementing an EHR system that ensures complete billing, coding and proper documentation of patient healthcare information
Taking measures to prevent falsification of EHR.
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