Documentation of Patient Strengths in Electronic Health Records.
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Examining the effects of electronic health records on the safety of patients in medical facilities.
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This study sought to determine physician, specialty and practice factors influencing choice of method for electronic health record (EHR) documentation: direct typing (DT), electronic transcription (ET), human transcription (HT), and scribes. A survey assessing physician documentation practices was developed and distributed online. The primary outcome was the proportion of physicians using each method. Secondary outcomes were provider-rated accuracy, efficiency, and ease of navigation on a 1-5 Likert scale. Means were compared using linear mixed models with Bonferroni adjustment. The 818 respondents were mostly outpatient (46%) adult (79%) physicians, practiced for a mean 15.8 years, and used DT for EHR documentation (72%). Emergency physicians were more likely to use scribes ( p < 0.0001). DT was rated less efficient than all other methods ( p < 0.0001). ET was rated less accurate than DT ( p < 0.001) and HT ( p < 0.001). HT was rated less easy to navigate than DT ( p = 0.002) and scribe ( p < 0.001), and ET less than scribe ( p = 0.002). Two hundred and forty-three respondents provided free-text comments that further described opinions. DT was the most commonly used EHR method but rated least efficient. Scribes were rated easy to navigate and efficient but infrequently used outside of emergency settings. Further innovation is needed to design systems responsive to all physician EHR needs.
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Q: When documenting care in the electronic medical record that someone else has provided, what is the responsibility of the person providing the care in documenting that he/she actually provided the care that someone else documented he/she did? Cosign? Progress note?A: Linda Harrington, rn, phd, cns, cphq, cenp, cphims, Lynn Choromanski, rn-bc, msn, Nancy Biddle, rn, msn, and Kimberly Acosta, rn, bsn, reply:To answer this question, we will provide a few definitions and case examples with screen shots, and we will discuss applicable law, standards, and guidelines. The answer is in part dependent upon hospital policy and the design of the electronic health record (EHR) being used.The following definitions are important to understand when answering this question.Authorship: attributing the origination of specific EHR content to a specific individual at a particular date and time.1Attestation: the act of applying an electronic signature to content in the EHR, demonstrating authorship and legal responsibility for a particular unit of data or information.1Electronic dual signatures, cosignatures, countersignatures: additional authorship signature(s) in situations when regulatory, law, facility policy, or clinical preference require multiple attestations on a particular unit of data or information.1Key to each of these definitions is the concept of “authorship.” The pertinent question deals with authorship of EHR data by persons other than the actual individual providing the care. More specifically, the question posed addresses whether documentation is the sole responsibility of the person who provided the care or whether attestation is an acceptable solution to clinical situations where direct authorship is not possible. These situations can arise for several reasons.A nurse has forgotten to document a medication. She goes home and calls back to ask the nurse who followed her to document it for her, as she will not be back to work for a period of time. In this or similar cases, nurses can document medications, tasks, or assessments done by others, if hospital policy permits. The user who is documenting is able to select the person for whom they are documenting by selecting “Mark as Done by Other.” This process occurs only if the documenting nurse is certain the event was completed and certain of who completed it. The nurse providing the care will be alerted upon returning to work that a task or a document is ready for an electronic signature in a portion of the application called Signature Manager. It should also be noted that the documenting nurse should not select “Mark as Not Done” unless absolutely certain the medication, task or assessment was not done (Figure 1).Under a different EHR design, nurses are able to use an option called “File for User.” This option is available in a similar case where a nurse leaves the hospital without charting an assessment or a medication. The other nurse authoring the data for his/her colleague chooses the “File for User” option within the screen and selects the name of the nurse who completed, in this case, the assessment. In the electronic audit trail, the name of the authoring nurse and the nurse who was selected in the “File for User” field will be attached to the data entered (Figure 2).In this case, a nurse has authored a task performed by another in the EHR. The nurse providing the care then cosigns the documentation of the person who originally documented the care (Figure 3). The nurse may also refuse to cosign if for some reason the information entered into the EHR is not correct, in which case hospital policy and procedure would dictate next steps for correction or retraction.2It is important to note that if the information is being entered into the EHR by one nurse based on paper documentation by another nurse used during EHR downtime, the paper documentation remains a part of the legal record.Federal regulations require each author take a specific action to verify and attest an entry into the medical record.1 The Medicare Conditions of Participation for Hospitals Section 482.24 of the Code of Federal Regulation states, “All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.” The hospital is required to have a policy that requires each author take a specific action to verify that the entry authenticated in the EHR is his or her entry or that he or she is responsible for the entry and that the entry is accurate. There may be additional state laws that should be considered.In addition to applicable law, regulatory standards should also be considered when developing policy and procedures related to documentation in the EHR. No current Joint Commission standards address the issue of nurses documenting or authoring data in the EHR for another individual providing the care. This situation was verified in a response from the Joint Commission to a question posed on their online standards question form (http://www.jointcommission.org/about/contactus.aspx).The American Health Information Management Association (AHIMA) provides helpful guidelines for developing a legal health record policy that take into consideration electronic health records.4 AHIMA acknowledges that at times the original documentation of care may be performed by a person other than the person providing the care. Their advice is that hospital policy should indicate when this is appropriate and how it will be handled considering the functionality of the hospital’s unique EHR. Similar to the Centers for Medicare and Medicaid Services, AHIMA also advises adherence to applicable state laws.Facilities with an EHR should have a clearly written policy and procedure that describes the process for authoring information on care provided by another clinician and the follow-up documentation required of the person providing the care. AHIMA provides excellent resources to assist in the development of such policies and procedures.4 Persons providing care should take responsibility to ensure that the care is appropriately documented. How this is accomplished will depend on hospital policy and the features of the EHR being used.
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A qualitative investigation into clinical documentation: why do clinicians document the way they do?
Background: Clinical documentation is a fundamental component of patient care. The transition from paper based to electronic medical records/electronic health records has highlighted a number of issues associated with documentation practices including duplication. Developing new ways to document the care provided to patients and in turn, persuading clinicians to accept a change, must be supported by evidence that a change is required. In Australia, there has been a limited number of studies exploring the clinical documentation practices and beliefs of clinicians. Objective: To gain an in-depth understanding of clinician documentation practices. Method: A qualitative design using semi-structured interviews with clinicians (allied health professionals, doctors (physicians) and nurses) working in a tertiary-level hospital in South-East Queensland, Australia. Results: Several themes emerged from the data: environmental factors, including departmental policy and systemic issues, and personal factors, including verification, clinical reasoning and experience influencing documentation practices. Conclusion: Our study identified that the documentation practices of clinicians are complex, being driven by both environmental and systemic factors and personal factors. This in turn leads to duplication and some redundancy. The documentation burden of duplication could be reduced by changes in policy, supported by multidisciplinary documentation procedures and electronic systems aligned with clinician workflows, while retaining some flexible documentation practices. The documentation practices of individuals, when considered from the perspective of enhancing quality care, are considered legitimate and therefore will continue to form part of the health (medical) record regardless of the format.
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Electronic health records : , Electronic health records : , کتابخانه دیجیتالی دانشگاه علوم پزشکی و خدمات درمانی شهید بهشتی
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