Documentation of Patient Strengths in Electronic Health Records.
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This Month Patient safety during the transition from paper to electronic health records Key words: electronic health record (EHR), documentation, paper documentation, electronic documentation, patient safety . Documentation needed for transitions from paper to electronic health records Key words: electronic health record (EHR), paper documentation, documentation . The meaning of electronic health record interoperability Key words: standardized nursing language, interoperability, Perioperative Nursing Data Set (PNDS) .
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The implementation of the electronic health record opened opportunities to enhance the quality of care through collaborative decision-making and fast tracked documentation. However, in order to gain from the benefits of electronic health records (EHRs), data captured need to be complete and timely. This paper reports on the electronic documentation of patients' records two years after the implementation of the EHR in an acute care hospital. The purpose was to assess the completeness and timeliness of electronic documentation and to elicit views of clinicians regarding the observed trends. Compliance was defined as availability of required documents and the presence of specific elements within the documents completed, within the stipulated time frame. The study used the hospital documentation policy to assess rate of compliance. A retrospective descriptive, explanatory design using electronic data extraction and structured checklists was utilised to collect quantitative data in five documents of In-Patient (IP) encounters. Semi-structured interviews were conducted with 6 clinicians, 4 physicians and 2 charge nurses. The rate of compliance showed a significant decline especially learning assessment, history and physical examination documentation. Clinicians cited both system and human issues as contributory factors.
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ObjectiveMedication documentation is a critical aspect of quality patient care. The current study examined whether electronic medical records provide medication documentation that is more complete and faster to retrieve than traditional paper records.
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Documentation in the patient record must be systematic and rigorous. However, each health care profession documents parts of the electronic health record (EHR) separately. This system can lead to double documentation. The aim of the study was to describe the amount of double documentation in health records for in-patients. A retrospective descriptive review of 30 records for in-patients diagnosed with hip fracture was conducted. Double documentation occurred on all records reviewed during the stay in hospital and in or between all professions reviewed. In total, 822 instances of double documentation were found. The EHRs available today are not designed to monitor processes. Instead, they follow each health profession, which can lead to double documentation. It would be desirable to develop an EHR from a process perspective and not a record per profession.
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The Centers for Medicare and Medicaid Services (CMS) continues to struggle with yet another set of documentation guidelines. Pediatricians are trying to work with the 1995 and 1997 guidelines. During the past year the government released an initial version of the 2000 Documentation Guidelines for evaluation and management (E/M) codes. These guidelines featured a large collection of vignettes that are to be used by physicians for comparison purposes when coding each E/M service. Medical specialty societies, via the American Medical Association (AMA), expressed extreme displeasure with these guidelines. The secretary of the Department of Health and Human Services put a stop to the project and announced the formation of a work group to study the many implications of documentation guidelines for E/M services. The American Academy of Pediatrics (AAP) has a representative in this work group.As this article goes to press, the work group has not issued a work product. Will 5 levels of medical service remain (99201–99205, 99211–99215)? Representatives from the CMS seem to favor restructuring this code set to 3 levels. However, the work group seems to favor maintaining the current 5 levels of care with less emphasis on history and physical examination and more emphasis on medical decision making.Documentation of E/M services justifies the physician’s choice of code for these services. Health Insurance Portability and Accountability Act (HIPAA) legislation requires the use of the standard code set for all electronically billed services. As the HIPAA implementation date (currently postponed to October 2003) comes closer, this CMS work product takes on more importance for medical services such as Medicare and Medicaid and the private sector. It may be prudent to wait for these revised guidelines before making expensive changes to office systems for documentation (eg, paper forms, electronic medical record), coding, and billing. While awaiting this work product from the CMS, the 1995 and 1997 guidelines are essential for Medicare services and, by extension, Medicaid and private payers.The AAP Section on Administration and Practice Management (SOAPM) has adopted many of the Bright Futures recommendations and has designed an initial set of AAP Visit Documentation Forms. Samples of these forms are shown above. The full set can be purchased through the AAP (888/227-1770). Widespread use of these forms may yield a standard of documentation even though the government may not address documentation for preventive health services. The AAP Visit Documentation Forms are appropriate for a pediatric initial history, family and social history, physical examination, and anticipatory guidance. The initial set of forms also includes acute and chronic problem lists and a medication record. The first set of forms covers birth through 2 years. Teen/adolescent forms are under development. After the CMS approves a final set of documentation guidelines for E/M services, SOAPM anticipates the completion of the documentation forms. The forms meet Medicaid Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) guidelines.The guidelines and forms are worth your consideration. For a complete list of the current 1995 and 1997 Documentation Guidelines, visit http://www.cms.gov/medlearn/emdoc.asp.
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