Clinical Doc. Improvement
kshlme
presentation1_holmes_karese.pptxHealth Record Documentation Policies
Written By: Karese Holmes
S
Health Record Documentation Policies
Purpose
The healthcare industry is grappling with several challenges due to significant changes. The nature of the complexity of the system, coupled with new legislations, spiraling costs, and other aspects have instigated the need to streamline the processes in the industry. Additionally, the need to improve the quality of patient care and cut down costs overrules. Subsequently, the call for integration of technology in corporate and other work organizations has been widespread in the 21st Century. The Department of Health Information Management is determined to streamline the hospital's information production, reproduction, and dissemination. Thus, it is introducing two vital policies: electronic signatures (E-signatures) and the copy and paste functionality. These policies seek to ease communication in the organization.
Use of Electronic Signatures
Subject:
To use E-Signatures (Digital Signature) to sign all patients documents
Purpose:
To help healthcare givers and stakeholders in replacing the outdated paper process, by eliminating the use of paper documenting. Also, maintaining regulatory compliance with the use of EHR/EMR.
Staff:
Will now use portable computers that are stationed within each room for documentation. Staff members will have each patient or consenting adult to sign all documentations on the portable computers.
Everyone will receive their logins and create a password
Forms will be designated to your area
Effective Date:
13 March 2017
Training will by held weekly to provide assistance
Use of Electronic Signatures
Description of Policy:
The electronic signature is used for health records as a means certify electronic health record entries, transcribed documents and patients signatures. This will help identify the author of the document, confirm consent and ensure the integrity is maintained for the life of the electronic health record. This document operates within a secured infrastructure, ensuring integrity of process and minimizing risk of unauthorized activity in the design, use and access of the electronic health record (AHIMA).
Definitions:
E-Signature: a generic, technology-neutral term for the various ways that an electronic record can be signed, including a digitized image of a signature, a name typed at the end of an email message by the signature, a biometric identifier, a secret code or PIN, or digital signature (AHIMA).
EHR: Electronic Health Record
EMR: Electronic Medical Record
Procedure:
The department guides that the implementation of the policy will undergo three stages. First, the department will offer educational training among the staff to introduce them to the new technologies. After that, a piloting study will be done for the policies to gather the strengths and weaknesses of the project. The feedback from the feasibility test will be analyzed and appraised. The policies will then proceed to the actual implementation.
Copy and Pasting
Subject:
How to effectively copy and paste data on within your portable computer.
Purpose:
Is to provide a faster more efficient way to transfer multiple documents within a patient health record. Saving time and providing quality healthcare to patients. Copy and Pasting allows the duplication of the notes and can be done within an individual patient’s record or across several patients’ record.
Staff:
Hold CTRL button on the keyboard with one finger and then press the C button with another finger. In pasting, the user holds the CTRL button with a single finger and presses V with another finger. The data copied will be pasted where needed.
Effective Date:
13 March 2017
Training will by held weekly to provide assistance
Copy and Pasting
Description of Policy:
Copy and paste s also referred to as the cloning function in healthcare documentation process. Cloning is not a strange idea (AHIMA, 2014). Rather, it is common with studies positing that 90 percent of doctors use the program in their daily routines. The technology is sure of improving the efficiency of data capturing. Moreover, it is timeless, consistent, and assures legibility and completeness of the data gathered.
Definitions:
Cloning- Cloning is used to refer to the process of copy and pasting. It has a genetically linked meaning. In EHR, it relates to the process of reproducing multiple copies that are similar to the original one.
Duplication- Duplication is the reproduction of several copies of the original data.
Signatory- Signatory is the legal term for a party that has penned a signature in agreement.
Encryption- Encryption refers to the technological conversion of data or information into code. It is done to eliminate unauthorized access to the information.
Procedure:
The department guides that the implementation of the policy will undergo three stages. First, the department will offer educational training among the staff to introduce them to the new technologies. After that, a piloting study will be done for the policies to gather the strengths and weaknesses of the project. The feedback from the feasibility test will be analyzed and appraised. The policies will then proceed to the actual implementation.
Reference
AHIMA. (2014). Appropriate Use of the Copy and Paste Functionality in Electronic Health Records. American Health Information Management Association Journal. Retrieved from: http://bok.ahima.org/PdfView? oid=300306
AHIMA. Electronic Signature, Attestation, and Authorship. American Health Information Management Association Journal. Retrieved from: http://bok.ahima.org/PdfView ? oid =107152
