What is the Role of EHR Documentation in Patient Safety and Quality of Care?

EHR Documentation

EHR implementation is not just about digitalization of paper charts. The EHR is designed to enable healthcare providers to deliver quality care to patients while maintaining their safety. The EHR includes comprehensive information regarding patient care such as demographics, progress notes, problems, medications, vital signs, medical history, immunizations, laboratory data, and imaging reports. Health care providers require access to complete and accurate electronic health records (EHRs) to provide patients with the best possible medical care. Medical transcription outsourcing is a practical strategy to ensure error-free and timely EHR documentation, which is crucial for patient safety and quality care.

According to recent studies, physicians spend up to 35% of their time on documentation (Appl Clin Inform., 2018). This has led to the increasing use of modalities such as speech recognition and medical transcription services to document patient-care encounters efficiently and effectively, maintain the integrity of the records, and deliver efficient patient care.

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How EHR Documentation supports Patient Safety and Care Delivery

EHR documentation supports patient safety and efficient care delivery in several ways:

  • Accurate and comprehensive information: EHRs provide a centralized repository for capturing and storing patient health information, including medical history, diagnoses, medications, allergies, and test results. Having access to complete and up-to-date information helps healthcare providers make informed decisions, reducing the risk of medical errors and improving patient safety.
  • Holistic view of the patient– Healthcare providers should aim to maintain dynamic patient-centered records that comprehensively track the care continuum throughout an individual’s lifetime, encompassing both periods of sickness and health. With a unified and continuous EHR, they can get a comprehensive perspective on the patient’s overall well-being, facilitating improved diagnoses and ensuring effective treatment plans that span their entire lifetime.
  • Reduces potential of medical errors: Medical errors include preventable adverse effects on patient care, which may or may not cause harm to patients. These errors can manifest as inaccurate or incomplete diagnoses, inappropriate treatment of diseases, injuries, behaviors, or other health conditions. According to an analysis of medical death rate data in the U.S. over an eight-year period by Johns Hopkins patient safety experts, more than 250,000 deaths per year are due to the medical errors. Some deaths are also due to adverse events of medications. Many medical errors are preventable.
    EHRs often incorporate decision support tools that provide healthcare providers with real-time alerts, reminders, and evidence-based guidelines. For instance, information recorded by a primary care provider in an EHR informs a clinician in the emergency department (ED) about a patient’s life-threatening allergy, allowing emergency staff to adjust care appropriately, even if the patient is unconscious. The EHR’s clinical decision support (CDS) feature plays a vital role in supporting healthcare providers in delivering safe and efficient healthcare, especially with the growing volume of medical information. These systems can help prevent medication errors, identify potential drug interactions or allergies, and prompt clinicians to follow best practices, ultimately improving patient safety. By aiding in speculation and mitigating preventable medical errors, the CDS enhances efficiency and promotes patient safety.
  • Streamlined workflows– EHRs enhance productivity and efficiency by reducing paperwork. Patients and staff are burdened with fewer forms to complete, allowing clinicians to allocate more time to patient care. Referrals and prescriptions can be swiftly transmitted, reducing wait times for appointments and prescription pickups. Automated reminders can notify patients about upcoming annual check-ups or prompt them to undergo regular screenings when necessary. Integrated patient tracking facilitates prompt filing of billing and insurance claims, ensuring timely processing and reimbursement.
  • Standardized and legible documentation: EHRs promote standardized and legible documentation through several mechanisms:
    • Structured templates capture patient information, such as medical histories, physical examinations, and progress notes in a consistent format. Structured templates also reduce the likelihood of missing critical information and promote legible documentation.
    • Dropdown menus and checkboxes for selecting common diagnoses, medications, procedures, and other clinical elements ensure that clinicians use predefined terms and codes, reducing variations and potential confusion.
    • Data validation and error checks automatically verify the accuracy and completeness of entered information, flagging potential errors or missing data, and prompt the user to make corrections.
    • The CDS provides alerts, reminders, and guidelines. These tools prompt the clinician to document specific details or order necessary tests based on established guidelines, ensuring standardized and comprehensive documentation.
    • Legible text and printing: Electronic documentation ensures that the text is clear and easily readable. EHRs also allow for printing or generating electronic copies of records, ensuring legible documentation for caregivers.
  • Care coordination and continuity: EHRs make real-time, patient-centered information securely and instantly available to all authorized users, including patients. EHRs facilitate seamless communication and collaboration among healthcare providers involved in a patient’s care. By sharing patient information electronically, care teams can function more effectively, leading to better care transitions, reduced duplication of tests or procedures, and improved patient outcomes.
  • Timely access to information: EHR platforms provide accurate, up-to-date, and complete information about patients at the point of care, ensuring that providers have access to all the information they need for better diagnoses and patient outcomes. They enable quick and secure access to patient data from multiple locations, such as hospitals, clinics, or emergency departments. The ability of the EHR to exchange information seamlessly across various disciplines, specialties, pharmacies, hospitals, and emergency response teams, coupled with the ability to access patient charts instantly through mobile devices, greatly enhances decision-making processes, especially in critical scenarios. Healthcare providers can retrieve critical information promptly, even in urgent situations, leading to faster decision-making and more efficient care delivery.
  • Patient engagement and empowerment: EHRs often include patient portals that allow individuals to access their own health records, review test results, request prescription refills, and communicate securely with their healthcare providers. A study published in the Patient Experience Journal that focused on the patient-facing aspects of the EHR, like patient portals and secure messaging, found that patient engagement technologies (P-Tech) enhance the patient experience because they enable patient data access and digital patient-provider communication. Findings indicated that the patient portal and other P-Tech helped support patient self-management. By actively involving patients in their care, EHRs promote patient engagement and empowerment, leading to better safety outcomes and improved care delivery.
  • Data analytics and population health management: EHRs provide rich structured data that can be analyzed to identify trends, patterns, and potential risks across patient populations. Healthcare organizations can leverage this information to proactively address gaps in care, implement preventive measures, and improve overall patient safety and outcomes.
  • Quality monitoring and reporting: EHRs support the tracking and reporting of key quality indicators and performance metrics. By monitoring these measures, healthcare organizations can find areas for improvement, implement evidence-based practices, and measure the impact of interventions on patient safety and care delivery.

Medical Transcription Outsourcing improves EHR Documentation

U.S. based medical transcription companies help healthcare providers to achieve their EHR optimization and care delivery goals. Outsourcing transcription to an expert allows providers to ensure accurate and precise documentation by leveraging the expertise of skilled transcriptionists who have knowledge of medical terminology and documentation standards, contributing to high-quality and error-free patient records. It also frees up valuable time for healthcare professionals to see more patients and deliver efficient care. Accurate EHR documentation enhances patient safety and efficient care delivery by providing accurate information, facilitating decision support, promoting standardized documentation, enabling care coordination, ensuring timely access to data, supporting data analytics, monitoring quality, and empowering patients to participate in their healthcare journey.

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