Electronic Documentation In A Healthcare Organization

Improved Essays
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…
Administrative, physical, and technical safeguards are just a few tools that can help in this process (Sanderson, 2009). Unless these tools are used appropriately, and according to policies and procedures put in place by the healthcare organization, integrity of the data may be questioned. Access controls, such as role-based authorization and audit trails in particular, can efficiently help healthcare facilities insure data integrity. Role-based authorization, “…limits access to patient information based on the user’s role in an organization” (Sanderson, 2009, p. 190). This overall helps ensure patient privacy. This tool meets the HIPAA standard of releasing only the minimum amount of information necessary to provide quality care. Implemented technology within a healthcare organization, “permits the system to prevent users from viewing or modifying any part of the record that is not directly related to their jobs” (Sanderson, 2009, p. 190). Audit trails can also be implemented in a healthcare facility to show who has accessed a computer or network and what operations were performed. A log such as this is monitored on a regular basis to insure that accurate information was

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