Enrich data by updating records rather than creating new records catching headlines for dating sites
Electronic documentation tools offer many features that are designed to increase both the quality and the utility of clinical documentation, enhancing communication between all healthcare providers.These features address traditional well-known requirements for documentation principles while supporting expansive new technologies.EHRs have customizable documentation applications that allow the use of templates and smart phrases to assist with documentation.
Healthcare organizations must manage information as an asset and adopt proactive decision making and oversight through information asset management, information governance, and enterprise information management (EIM) to achieve data trustworthiness.
An accurate information governance program will ensure the accountability of how information is managed and the information’s integrity.
HIM professionals consistently identify the following documentation practices as problematic in EHRs.
There are a number of existing rules and regulations on documentation principles and guidelines that primarily address documentation authorship principles, auditing, and forms development in a paper health record.
New guidelines are being sought by the healthcare industry that ensure and preserve documentation integrity in an age of electronic exchange and changes in the legal evidentiary requirements for electronic business and health records.