Electronic health records (EHRs) offer many benefits such as improved patient care, better care coordination, improved diagnostic ability and better patient care, increased patient participation, improved practice efficiencies and cost savings. Medical transcription companies help physicians document a wide variety of reports, save time, overcome stress, and focus on care. EHR documentation integrity is essential to realize the benefits of EHRs. The three “Rs” of well-kept, accurate and complete medical records are:
- The right information
- At the right time
- For the right patient
Loss of documentation integrity can undermine patient care, affect compliance, and lead to legal issues.
What are the factors that compromise EHR documentation integrity? Experience shows that integrity issues are directly related to EHR automated functions and short-cuts.
- “Copy and paste” or cloning: Copying and pasting allows users to copy text verbatim from any note and paste it into any another location. Common copy-paste errors include not updating the information, mistakes in the time element of a visit, contradictory information in a note, lack of clarity on authorship, and omitting relevant data when cutting and pasting (www.eyecareleaders.com). It can also lead to bloated notes that make it hard to find relevant new information.
- Automatic fill-ins: While auto-fills can facilitate documentation and save time, invalid auto-population of data fields can lead to major errors. Verifying auto-populated entries is necessary to identify real from incorrect data.
- Drop down menus: Data can be automatically entered in drop down menus for diagnoses if the provider holds the mouse over them too long.
- Carry or pull forward entries: This refers to carrying forward the same notes from past entries and the same plan of care. The copy forward command allows bringing forward parts of or the whole previous note into a new progress note. It is useful to update structured information such as blood pressure, labs and medications. But errors occur when the physician does not verify if the information carried forward is pertinent to the current encounter. One study of a medical intensive care found that 74% of attending physicians’ EHR notes and 82% of residents’ notes had at least 20% of the information copied from previous notes (ACP Hospitalist). This can create a lot of confusion as to what was done and when it was done.
- Auto prompts: While auto‐prompts can support and improve provider documentation, they can also be misused. Prompt fatigue, a result of inability to control prompt occurrence, can lead to the physician not using it or even misusing it when entering information.
Good document keeping is an essential element in healthcare. The concerns about the accuracy and quality of EHR documentation started right from the time EHRs were introduced and continue to exist even today. In an update published in 2017, the American Health Information Management Association (AHIMA) stressed the importance of having processes in place” to ensure the documentation for the health information used in care, research, and health management is valid, accurate, complete, trustworthy, and timely”.
Following these best practices can help physicians preserve EHR documentation integrity:
- Document the health services provided to each patient separately from all others.
- Avoid copying forward a previous finding or section of an exam that is not pertinent to the current visit or progress note. If a prior finding is copied forward, it should be edited as appropriate. At each encounter, the physician must ensure that what is documented is appropriate and correct.
- Check dictated information for errors. Before sending dictated files to a medical transcription service provider, physicians need to review, edit and validate dictated information. The AHIMA report notes that organizations using a speech recognition tool (SRT) without checks in place experience significant data quality problems and documentation errors.
- Set up a patient identity integrity program to ensure that information is recorded on the correct medical record. Organizations should ensure that key demographic data are correct. Errors in patient identification can have a ripple effect across the healthcare network and compromise patient safety.
- All information created within the EHR should be linked to its author. This is important as multiple providers contribute to an EHR note. The signatures of all authors or contributors should be preserved so that each individual’s entry can be clearly identified.
- Rules on amending EHR documentation should be diligently followed. Every healthcare organization needs to have policies and procedures in place regarding when changes need to be made, the type of changes that can be made, who can amend the documentation, and how the changes will be tracked and supervised, notes the AHIMA report.
- Conduct audits. Providers should perform EHR data audits to review templates. By identifying and pointing out instances of poor documentation, audits can help organizations educate providers on improving templates.
- Educate providers. EHR users must be trained about EHR documentation requirements, security requirements, and compliance and legal risks, including their own responsibility in preventing problems.
Medical records can support clinical decision-making only if they contain reliable information. Information that is inaccurate, contradictory or hard to find can compromise care and patient safety. Outsourcing medical transcription is a viable option to ensure accurate and timely documentation and preserve the integrity of patient medical records.