For questions or training on coding and documentation, contact the ACR Practice Management Department at [email protected].
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Explore This IssueJanuary 2018
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General Policy for Documentation in an Electronic Health Record
Subject: Documentation guidelines for EHR
Purpose: To ensure complete, accurate and timely electronic health records
Staff Governed by This Policy: ________________________________________________________
Effective Date: _____________________________________________________________________
Date Reviewed or Revised: __________________________________________________________
Distribution: All persons governed
EHR (Electronic Health Record) content shall be in compliance with standards established by JCAHO (Joint Commission on Accreditation of Health Care Organizations) and ___________________________ practice, and shall also comply with requirements in third-party payment programs or with licensure requirements of special programs. All patient care documentation will be entered by provider data entry, transcription, uploading and document scanning. Electronically stored patient information is subject to the same medical and legal requirements as the hand-written information in the health record.
Definition of Terms
- Health Record—the chronological documentation (paper or electronic format) of healthcare and medical treatment given to a patient by professional members of the healthcare team. It is an accurate, prompt recording of their observations, including relevant information about the patient, the patient’s progress and the results of treatment.
- The health record will contain sufficient information to identify the patient; justify diagnoses and treatment; document results of care or treatment; describe the condition of patient upon discharge; and document instructions to the patient regarding follow-up care, activity levels and necessary medications.
- Entries must be accurate, relevant, timely and complete.
- Irrelevant text needs to be omitted. Concise notes are more readable than lengthy notes.
- Appropriate note titles must be matched to note content and the credentials of the author. This enhances the ability to find a note more quickly and easily.
- Notes must be reviewed and signed promptly.
- Viewing of unsigned notes is allowed by pharmacy only due to the risk of clinical decision making based on data that may be changed or deleted. Other limited access to unsigned notes may be determined by local policy.
- EHR users must respond quickly to notifications, which prompt them about documents requiring authentication or additional information.
- The electronic function of copy and paste must be used with caution and according to strict and enforceable policy.
- Never copy the signature block into another note;
- Never copy data or information that identifies a healthcare provider as involved in care that he/she is not involved in;
- Do not copy entire laboratory findings, radiology reports and other information in the record verbatim into a note. Data copied must be specific and pertinent to the care provided; and
- Do not re-enter previously recorded data.
- Authentication includes the identity and professional discipline of the author, the date and the time signed. Notes made and authenticated by healthcare team members must be individually identified either by the use of the individual’s title or by the appropriate credential designation. Once affixed, authentication on electronic documents cannot be rescinded or retracted.
- No edit or alteration of any documentation or electronic signature, which has been completed, can occur without approval of the practice administrator or managing partner.
- The author must initiate any retraction or rescission of any entry or originating discipline (i.e., laboratory and radiology are examples of disciplines that may initiate retractions or rescissions within their packages).
- An addendum to a note is made when a healthcare provider deems it necessary to clarify information recorded in the original document or to add to the original document.
- Addenda are linked to the original created document;
- Addenda must be authenticated in approved manner; and
- Addenda must not be backdated.
- The Office of Inspector General. Report (OEI-04-10-00181): Improper payments for evaluation and management services cost Medicare billions in 2010. 2014 May 28.
- McCann E. CMS called out for EHR fraud failings: Deficiencies helped contribute to $75B to $250B in healthcare fraud each year, says OIG. Healthcare IT News. 2014 Jan 9.
- Hammond KW, Helbig ST, Benson CC, et al. Are electronic medical records trustworthy? Observations on copying, pasting, and duplication. AMIA Annu Symp Proc. 2003; 2003: 269–273.
- Documentation and level of service—Evaluation and management services. Noridian Healthcare Solutions. 2015 Jul 16.