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Accurate note taking and documentation protects patient records.
Setting documentation policies for your office will help you stay in compliance and record information accurately, while also making your documentation process more efficient and effective.
To boost your EHR documentation’s accuracy, refer to these best practices and conduct ongoing audits.
Preventing common documentation mistakes
Preventing mistakes in the first place may be easier than searching for errors later. Accurate records start with accurate documentation. You can reduce mistakes by implementing basic best practices such as controlling access to your EHR, preventing issues created by copying and using templates, reviewing dictated data and records, and ensuring that patients are correctly identified.¹
If you understand how EHR errors happen, you can develop your own prevention strategy. The American Health Information Management Association (AHIMA) identifies the following practices as common causes of documentation mistakes:¹
- Using Templates: While using templates may speed up the documentation process, they also create over-documentation problems and mismatched records that conflict with accurate patient data. Templates designed to facilitate billing and reimbursement approval may be over or under-billing. Vital information for your patient’s health may be missing entirely.
- Copying: When you copy documentation from another patient or another encounter, you are essentially creating a template. Signs of bad copying include identical vital signs or test results from different encounters and the same descriptions of symptoms or observations found in different patient records.
- Using Dictation Software: Voice recognition software may record your dictated notes inaccurately, introducing errors. If you use this software, make sure you have a process of reviewing dictated notes for accuracy.
- Identifying Patients and Records Incorrectly: Entering patient information into the wrong record can occur. EHR features such as software that identifies inconsistencies in patient identification may help prevent these problems. Verifying patient data such as by birth date may prevent basic identification mistakes.
- Unknown Authors: Each author with access to patient records should leave a signature indicating record changes they made.
- Not Tracking Changes and Corrections: As more authors change documentation within a record, the potential for mistakes increases. EHR should allow for back-tracking within the record. EHR should record information about documentation changes, as required by HIPAA standards. Tracking changes accurately can also help identify fraudulent changes to records. In fact, the act of tracking may deter fraud.
- Not Recording Audit Information: Fraudulent audits may be created for the purpose of disguising misuse, so you should track audits carefully.
Administrative and software solutions
Getting the most out of your EHR notes often requires a combination of administrative and software strategies. Protecting accuracy reduces waste by allowing you to increase efficiency without sacrificing information quality. The Centers for Medicare and Medicaid Services (CMS) suggest using policies and custom software features to increase the effectiveness of EHR notes. By establishing policies for finding and reporting mistakes, you may continue using copying, templates, and other techniques responsibly.²
You can designate specific roles in your office for auditing records while also using specific office policies to explain how each member of your team is responsible for information accuracy. Customizing your software to alert users to potential problems automatically can help prevent documentation errors, streamlining your auditing process.²
Making your own solutions
By asking your vendor for help, you can create your own solutions and learn how to use your EHR more effectively. Obtaining ongoing training in using your software can also help you generate new ideas for boosting efficiency while also improving accuracy.
About ACOM Health
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¹AHIMA. “Integrity of the Healthcare Record: Best Practices for EHR Documentation (2013 update).” American Health Information Management Association (AHIMA). http://library.ahima.org/doc?oid=300257#.V2BsrJBHarV. Accessed June 2016.
²CMS. “Documentation Integrity in Electronic Health Records.” Centers for Medicare and Medicaid Services (CMS). https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/ehr-docintegrity-factsheet.pdf. Published July 2015. Accessed June 2016.