Enrich data by updating records rather than creating new records
Organizations must develop policies designed to address inappropriate use of these tools to minimize non-compliance.
Common documentation risks that can result from cloning features include: Providers must recognize that every patient is unique and must ensure that the health service provided is documented distinctly from all others.
Organizations using voice recognition without a validation step in place are experiencing significant data quality problems and documentation errors.
Organizations should have in place a process to ensure providers review, edit, and approve dictated information in a timely manner.
The scenarios further illustrate that while helping to improve apparent timeliness and legibility of documentation, additional adverse effects were created by the inability to verify actual authors or to authenticate services provided at any given time.
From a billing perspective, defaulting or copying and pasting clinical information with previous existing documentation from other patient encounters in a different health record facilitates billing at a higher level of service than was actually provided.
Electronic documentation tools offer many features that are designed to increase both the quality and the utility of clinical documentation, enhancing communication between all healthcare providers.
These features address traditional well-known requirements for documentation principles while supporting expansive new technologies.
These scenarios show how the ability to copy previous entries and paste into a current entry can lead to a record where a provider may, upon signing the documentation, unwittingly attest to the accuracy and comprehensiveness of substantial amounts of duplicated or inapplicable information, as well as the incorporation of misleading or erroneous documentation.
Use of these features without appropriate management and guidelines, however, may create information integrity concerns such as invalid auto-population of data fields and manufactured documentation aimed to enhance expected reimbursement.