Documentation Integrity In Healthcare Organization

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Today many healthcare organizations face challenges regarding the maintenance of documentation integrity in their electronic healthcare records (EHR). Accuracy in documentation is critical for a healthcare organization as it seeks to provide high-quality care for its patients. An electronic health record (EHR), as well as current health information technology (HIT) is important to a healthcare organization in order to provide care that is efficient and safer for its patients. Through accurately completing health records, implementing policies and procedures, and putting safeguards into place within the healthcare organization can improve data integrity in the electronic health records (EHR) system while helping the healthcare organization achieve …show more content…
Electronic documentation in a healthcare organization is key to improving workflow processes. By using electronic documentation, healthcare organizations can eliminate duplicate documentation and redundancies, therefore streamlining the documentation process (Integrity of the Healthcare Record: Best Practices for EHR Documentation, 2013). Electronic documentation tools that are available to healthcare organizations offer features that are designed to increase both the quality and efficiency of clinical documentation. Clinical documentation, according to Sanderson (2009) includes, “…all pertinent data collected in the course of providing care during a patient’s hospital stay” (p. 114). Clinical documentation is very similar to documentation described by Segen’s Medical Dictionary. It requires complete, up-to-date information to make the best treatment decisions, which can be difficult when information is inaccurate or missing from the patient’s …show more content…
According to the article Integrity of the Healthcare Record: Best Practices for EHR Documentation (2013), “Providers must recognize each encounter as a standalone record, and ensure the documentation within that encounter reflects the level of service actually provided and meets payer requirements for appropriate reimbursement.” It is critical for healthcare organizations to seek accuracy in the patient documentation process. The article Assessing and Improving EHR Data Quality (2013) suggests that documentation and data content within an electronic health record (EHR) must be, “…accurate, complete, concise, consistent, and universally understood by data users, and must support the legal business record of the organization by maintaining these parameters. It is critical that both structured and unstructured data meet a standard of quality if they are to be meaningful for internal and external use, such as for continuum of care and secondary purposes.” If documentation is not done correctly, data integrity may be questioned, as well as whether fraudulent activity took place. Inaccurate documentation may also lead to inaccurate reimbursement. “Poor documentation, inaccurate data, and insufficient communication,” according to the article Assessing and Improving EHR Data Quality (2013),

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