This monthly column will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.
By Neysa Noreen, MS, RHIA
Technology does not always function as planned, even now in the era of electronic health records (EHRs). This is the unfortunate reality facing healthcare provider organizations. Proper documentation is essential for data integrity and the integrity of the medical record. This documentation enables staff to identify when a system issue has occurred and to determine the impact on the medical record.
It is important for organizations to have a plan for how to document when data integrity in the medical record is compromised due to a technology issue. System issues may impact one or thousands of medical records. A documentation plan needs to be developed for each possible scenario. These plans must help future readers of the medical record easily identify the issue. If this information is not identifiable, serious patient safety events could occur. Other concerns with not identifying these issues are data report inaccuracies and possible unauthorized disclosures.
There are multiple ways of documenting in the EHR. Techniques used may vary based on the severity of the issue and the number of medical records impacted. In the event of a major system issue impacting thousands of patients, a general statement should be documented in the EHR. This could be done by creating a general statement and then working with the EHR vendor to push the statement to all patients impacted. The organization will need to decide on a location within the EHR for these statements. Using a hierarchy location such as legal allows users to easily find the documentation because of the unique naming convention. Moderate or smaller system issues should be addressed per medical record. Identifying specifics to each medical record increases confidence that the system issue was addressed and the impact analyzed adequately. A paper form describing the details should be created and signed by impacted parties depending on the issue. If the system did not impact users documenting within the medical record, a form explaining the details should be created and signed by the director of health information management. This form should be scanned to the legal section of the medical record for future reference.
Documenting system-created issues is critical for the integrity of the EHR. While it is important to document within the EHR, a system log should also be kept and used for tracking purposes. This log should identify the patients impacted, date the system issue occurred, date the issue was resolved, who resolved the issue, and how the issue was resolved. Taking these steps will help ensure the integrity of the patient medical record and prevent patient harm.
Click the links below to access sample policy/procedure and medical record error correction form examples.
- Sample Policy
- Medical Record Error Correction Sample 1
- Medical Record Error Correction Sample 2
- Medical Record Error Correction Sample 3
Neysa Noreen (firstname.lastname@example.org) is inpatient coding and CDI manager, health information management at Children’s Hospitals and Clinics of Minnesota.