This article is published in sponsorship with Berkeley Research Group (BRG).

By BRG HIM and Healthcare Technology Staff


A physician approaches a health information management (HIM) staff member, upset because the location of a document in their office is not in the same location in the hospital record. Coding professionals miss procedures performed because the “Code Blue” form cannot be found. The electronic system flags a physician for a deficiency as the history and physical is in the consult section, and the physician is angry about being asked to complete work again that has already been performed. Quality reviewers cannot find information needed for state reporting. Attorneys are unhappy because information received is difficult to find in the printout of an electronic medical record.

Does this sound like a typical day in the life of HIM, immediately following a “full” electronic health record (EHR) implementation?

Many HIM professionals couldn’t wait until the health record was available electronically, which would lessen frustrations with illegible documentation and provide the entire record at their fingertips. Now that the record is available electronically, physicians, physician offices, quality reviewers, and coding professionals face a multitude of challenges. One that frequently comes up after an EHR implementation is the ability to readily locate the documentation. How should this challenge be overcome, and who can assist?

The advent of the EHR created opportunities for the HIM department to lead the transition from paper to electronic formats. Process development, management, and oversight of the record are hallmark skills of HIM professionals and should be used to aid in this transition, especially with standardization of the record to ensure that records are complete. It’s critical that organizations work to standardize the EHR across the system to alleviate frustrations and help reduce the opportunity to miss critical documentation, such as illnesses and treatment information, patient instructions, and allergies that are central to quality patient care.

Transitioning to use of a single, cohesive electronic record for the hospital-based physician clinic/office and the hospital outpatient/inpatient areas has surfaced new issues, particularly around the forms used in the record. Previously, the records were completely separate, and in many cases, oversight to ensure completeness was under different ownership. Now records are required to be located in the same system, requiring standardization of the location, names, and quality of the forms.

Challenges exist in part due to the different purposes of a physician office note versus a multi-day inpatient encounter. Because this documentation must now coexist in the same record, a logically organized chart is more important than ever. Change control processes must be established to govern the creation and placement of “electronic” and/or “paper” forms. This process should include:

  • The establishment of a Forms Committee comprised of senior HIM and physician leadership, responsible for reviewing and approving requests and establishing standard forms management policies
  • A clearly delineated breakdown of department responsibility covering form design, implementation, and ongoing maintenance
  • Guidelines for submission of new form requests
  • A communication plan to announce availability of new forms, when approved and created

Many documents are created with essentially the same information, with only minor modifications for physician-specific requirements. The organization must define an approval methodology of how forms are requested, and where and how forms (electronic data or paper) are named and sequenced in the record.

A Forms Committee will address these issues by providing governance to the forms change control process, ensuring that decisions are being made that align with the organization’s best practices and strategic goals. Form Requests should clearly identify the reason and need for the form, along with any regulatory requirements, a mock design of the proposed form, and contact information from the requesting department’s point of contact. The Forms Committee will review requests and oversee a standardized process that ensures that new forms:

  • Use a standard naming convention
  • Are indexed logically in the chart
  • Align with the organization’s strategic and business goals
  • Met Centers for Medicare and Medicaid Services (CMS), Joint Commission, federal and state initiatives, and coding requirements
  • Comply with the organization’s data-sharing protocols
  • Are designed with respect to end user productivity and workflow preferences
  • Generate an output that meets the needs of the requesting department

Once approved, a HIM team member will notify the point of contact from the requesting department, advising them on who would be responsible for designing the form, where the document would be located in the record, and what the document-naming convention would be.

The advantage at that point for HIM would allow systematic training of staff on new forms, their purpose and placement in the chart, and whether deficiencies would be required.

This placement of documentation in the record requires negotiation, as the “paper” world often clashes with the “electronic” world. A single format for placement of documents that works for the inpatient, outpatient, and clinic would require sharing ownership of the form. Physician offices and specialty departments may feel a loss of control when their office/clinic cannot have an office-specific format that was formerly used. This is where patience is a virtue in helping soothe ruffled feathers, thus creating quality of care and increased access to records throughout the system.

Advantages of a coordinated, standardized record include consistent location of information and easy identification of missing documentation, ensuring consistent location of documentation for coding. Developing partnerships with clinicians, ancillary staff, and information systems at the initiation of an EHR implementation is ideal. These relationships will need to be maintained to achieve and sustain a standardized record.

Standardized documentation provides information for quality patient care and quality initiatives. It ensures regulatory requirements are met and offers the opportunity to ensure a “defensible” position for legal purposes and coding and billing requirements. It also allows HIM professionals to certify the record’s completeness, accuracy, and authenticity with confidence.

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The views and opinions expressed in this article are those of the author and do not necessarily reflect the opinions, position, or policy of Berkeley Research Group, LLC or its other employees and affiliates.