Staying HIPAA compliant is one of the most important aspects of maintaining your healthcare facility. With so many data breaches and violations surrounding the protection of PHI, taking a look at how facilities are using EHRs to document patient information is a major concern. Using technology to enhance patient care has made great strides in the healthcare environment, but these advancements can also increase the chances of fraudulent or inappropriate documentation, especially if the system being used is subpar.
How can clinical documentation be improved within an EHR? Here are a few suggestions:
• Outline the primary focus of the software - Many facilities use software that they do not understand, or do not have specific objectives for its use. By placing improvement of clinical outcomes and patient care support as the primary focus, the level of clinical documentation can improve.
• Have defined standards - A clearly outlined set of professional standards for clinical documentation and its practices should be present in each organization. This should include giving patients access to their medical records to increase engagement, and capturing structured data only when it is useful or necessary in the care and delivery of quality assessment and reporting
• Identify best practices - Organizations should perform comprehensive research to identify and develop best practices for clinical documentation to assist in determining the creation and use of professional standards within their organization.
As many organizations continue to move toward customized EHR design, there are a few things to consider:
• Optimization of the system for care delivery over a period of time, including patient care that involves collaborative teams of patients and clinicians;
• Making clinical documentation within the EHR system an intuitive design;
• Creating EHRs that support the use of embedded tags for identification, and a “write once, reuse again” approach for ease-of-use, flexibility and expediency.
• Interpretation of the data to conclude whether or not an action has been taken to alleviate extra steps by the clinician; and
• Integration of patient-generated data to further reinforce patient/clinician collaboration.
Visit here for more information of OR Protocols because These protocols and steps can help in the development of improved clinical documentation and the use of EHRs within the facility to help alleviate data breaches and expand the levels of protection for PHI.
How can clinical documentation be improved within an EHR? Here are a few suggestions:
• Outline the primary focus of the software - Many facilities use software that they do not understand, or do not have specific objectives for its use. By placing improvement of clinical outcomes and patient care support as the primary focus, the level of clinical documentation can improve.
• Have defined standards - A clearly outlined set of professional standards for clinical documentation and its practices should be present in each organization. This should include giving patients access to their medical records to increase engagement, and capturing structured data only when it is useful or necessary in the care and delivery of quality assessment and reporting
• Identify best practices - Organizations should perform comprehensive research to identify and develop best practices for clinical documentation to assist in determining the creation and use of professional standards within their organization.
As many organizations continue to move toward customized EHR design, there are a few things to consider:
• Optimization of the system for care delivery over a period of time, including patient care that involves collaborative teams of patients and clinicians;
• Making clinical documentation within the EHR system an intuitive design;
• Creating EHRs that support the use of embedded tags for identification, and a “write once, reuse again” approach for ease-of-use, flexibility and expediency.
• Interpretation of the data to conclude whether or not an action has been taken to alleviate extra steps by the clinician; and
• Integration of patient-generated data to further reinforce patient/clinician collaboration.
Visit here for more information of OR Protocols because These protocols and steps can help in the development of improved clinical documentation and the use of EHRs within the facility to help alleviate data breaches and expand the levels of protection for PHI.
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