Accurate record-keeping is an integral element in providing safe and effective patient care. Far more than a computerized version of a paper chart, an electronic health record (EHR) contains information such as administrative and billing data, patient demographics, progress notes, vital signs, medical histories, diagnoses, medications, immunization dates, allergies, radiology images, and lab and test results. Good clinical record keeping is essential to promote effective communication between different healthcare professionals involved in the patient’s care and enable continuity of care. Poor clinical record keeping can increase medico-legal risks and lead to serious incidents. Well aware of these facts, medical transcription companies help healthcare professionals maintain timely and accurate patient records.
Providers are expected to provide legible, factual, complete, clear, consistent, precise, and reliable documentation of a patient’s health history, present illness, and course of treatment. The documentation of the clinical encounter includes observations, evidence of medical decision making in arriving at a diagnosis, treatment plan, and outcomes of all tests, procedures, and treatments.
EHRs have not lessened the significance of narrative notes which provides the basis for the healthcare provider’s decision-making process. EHR-facilitated documentation with dropdown fields and multi-pick boxes are not a substitute for physicians’ narrative reports. All communication with the patient, family members or other caregivers should be scrupulously documented. Narrative notes are crucial for important clinical events such as events, consent discussions, transfer of care, and changes in patient condition.
For each entry and action, the EHR should capture each healthcare provider’s identification automatically. This applies for actions such as data entry, modification, and deletion. Well integrated and seamless documentation of progress notes of all healthcare providers is necessary to avoid communication problems.
In paper records, edited, corrected, or deleted notes may be easily visible. However, this is not so with the EHR. The system should be able to track who made the change, the date on which change was made, and the reason for the change. Audits are necessary to track modification of electronic health information. The original information should be visible and easily retrievable by healthcare providers and other users.
Much has been said about the EHR’s copy-paste function, which allows a user to copy information from a prior note and paste it into a new note. Using copy-paste indiscriminately comes with risks such as inaccurate information, repeated information and documentation bloat, reproduction of potential errors in the documentation. This practice can cause serious errors, negatively impact care, affect the credibility of the patient record and the healthcare provider, and increase risks of malpractice.
Finally, EHRs must be stored securely and should be retained following the state’s policy.
An article in Paediatr Child Health lists the following best practices for appropriate use of EHRs:
- Separate routine data entry from the patient encounter: An article in Paediatr Child Health says that separating routine data entry from the patient encounter will improve patient satisfaction. Reviewing the list of concerns, problems and previous notes before entering the examination room will provide more time for physician-patient communication. The EHR can be accessed during transition times.
- Listen to the patient’s concerns before entering data: Physicians should allow patients to communicate their concerns before they begin entering information in the EHR. Patients should not be interrupted from expressing themselves.
- Involve the patient in building the chart: Allowing the patient to actively participate in chart building will improve the patient-physician relationship and also promote patient confidence in the care they receive. Patients can also be shown the trend of their results.
- Improve computer and typing skills: Researchers recommend that physicians improve screen-scanning speed, browsing speed and accuracy, and learn to use the decision support effectively.
The key to good clinical documentation is to know exactly what is relevant to document, and being able to concisely summarize and report main concerns. Healthcare organizations should develop clear policy and procedures, education and training to support good documentation practices and proper EHR use. Providers can outsource medical transcription to ensure accurate documentation of physician notes for integration into the EHR.
