How To Improve Your EHR Documentation

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There’s no denying that the growth of computer and internet technologies has changed our lives, in most cases for the better. Computing equipment and online resources allow for the convenience of instant access to information, space-saving data storage, and increased opportunities for communication and sharing of data.

This is not only beneficial to individuals, but also to businesses, most of which have found ways to integrate technological advances in order to improve operations. The healthcare industry is no exception, and the growing use of electronic health records (EHRs) has revolutionized the way most medical practices conduct business.

Naturally, there is often a downside to change. Although EHRs make data collection, storage, and sharing easier than ever, the major concern with switching to digital documentation is preserving the integrity of information.

It is vital that health records be accurate, complete, and up-to-date so that both patients and doctors have access to all applicable information when making determinations about diagnosis and treatment. In addition, these records are used for the purposes of billing. If they are inaccurate or incomplete in some way, healthcare providers may not be able to secure payment for services.

In other words, you may be interested in improving your EHR documentation. Here are a few ways in which you can ensure the highest level of document integrity.

ehr-documentationCommon Sense Solutions
When selecting appropriate software solutions for implementing a system of EHRs, it’s important to consider necessary functionality. As a healthcare provider, you no doubt have some ideas about essential features you would like to see included.

From a practical perspective, your operation requires efficiency, which means a simple, easy-to-navigate interface. On the other hand, you also want tools that allow for not only the documentation of patient history, symptoms, diagnoses, and treatments, but also the thought process and considerations that goes into patient care. You need tools for both data collection and interpretation.

Improved EHR documentation requires that you first find suitable software solutions that take your particular needs into account. Like any type of purchase, this means shopping around and testing products.

Policies and Procedures
Once you have selected appropriate EHR programming for your healthcare practice, it’s time to set policies and procedures for usage. Starting is easy because you can simply follow existing government rules and regulations, such as those provided by HIPAA.

However, you may want to add your own policies and procedures for proper management within your particular healthcare setting. You’re bound to have your own unique standards for managing EHRs that make sense for your operation.

It is extremely important to make sure that everyone in your healthcare organization is properly trained to use software and follow procedural guidelines when it comes to collecting, storing, copying, and transmitting patient data electronically. The ultimate goal of any EHR system is to improve patient care and coordination. This is not possible if data is inaccurate, incomplete, or misplaced.

Many software providers offer tutorials or even training sessions to get users up to speed with their programs and detail the features that users will employ. However, supplemental training for your organization should include an overview of applicable laws, policies, and procedures. Proper training is essential to improving EHR documentation.

Creating templates can be a useful means of streamlining operations; increasing efficiency and cutting out unnecessary steps. It can also be detrimental to data collection if it fails to account for necessary fields for entering information.

The thing to remember with templates is that they are merely tools. In many instances they will be useful for organizations that follow the same formats frequently, but if they turn out to be the wrong tools for the job, having more comprehensive options available is essential.

Copy with Care
One of the worst culprits when it comes to EHR integrity is the practice of copying or cloning information, and the problems are twofold. First, if information is inaccurate or incomplete to begin with, copying it to new documents only perpetuates the problem.

Second, copied information can confuse the source. When information is inaccurate in some way, it may be important to determine where it came from, or more specifically, who entered it incorrectly in the first place. This can be difficult to determine when data has been copied.

Although copying or cloning data may be convenient, it is something that should be done with care. Data should always be validated, upon entry and prior to being copied. Instituting a policy that requires checking and double checking data entered into EHRs is imperative when improving documentation.

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