2015;20(2):6. EHR means Electronic Health Record with the word “health” covering more in-depth information about a person’s overall health. Electro nic 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. Legible, complete documentation that facilitates accurate coding and billing; Interfaces with labs, registries, and other EHRs; Safer, more reliable prescribing Such anecdotal notes … Phillips W, Fleming D. Ethical concerns in the use of electronic medical records. Proper documentation remains the best means of communicating patient health status & plans of care. 2017; 43(10):540-7. 2013;51(4 Suppl 2):S15-22. 2016;30(36):34-42. March 31, 2015. jointcommission.org/assets/1/6/SEA_54_HIT_4_26_16.pdf. An EHR is a digital version of a patient’s paper chart and broader health history designed to be used both internally and externally by multiple entities. Janet Pagulayan the nursing informatics coordinator. An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. Legal, ethical and billing compliance principles that apply to electronic documentation are no different than those governing traditional handwritten notes. Clinical documentation supports patient care, improves clinical outcomes, and enhances interprofessional communication. ... Electronic Health Records … With our goal of integrating the nursing process with the EHR, we adopted the American Nurses Association’s definition of the nursing process as “an assertive, problem-solving approach to the identi- fication and treatment of patient problems.” (See Make the connection.) First, EHRs have built in “… Subsequent auditing (3, 6, and 9 months after education) shows improved documentation in areas with significant effect on patient care and safety, including these 3-month results: As with every change project, leadership commitment is key. Copyright © 2006–2020 American College of Rheumatology. An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. After all of the problems were identified, we chose nurse champions who were trained to continue chart audits and proper documentation, using the nursing process model on a larger scale. Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. The OIG report, Improper Payments for Evaluation and Management Services Cost Medicare Billions in 2010, gives clear instructions for the Centers for Medicare & Medicaid Services (CMS) to educate providers on coding and documentation requirements for E/M services, and to continue to have CMS contractors review E/M services billed for high-coding physicians as well as continuous review of E/M services that are paid in error.1 Due to the findings in the report, contractors initiated various programs to monitor documentation requirements for E/M services and, due to high error rates, began issuing prepayment reviews through the comprehensive error rate testing (CERT). “The EHR touches every part of a health system’s work and mission, so the governance committee should be multidisciplinary. The Rheumatologist reaches 11,500 rheumatologists, internists, orthopedic surgeons, nurse practitioners, physician assistants, nurses, and other healthcare professionals who practice, research, or teach in the field of rheumatology. Problem and Significance The Clinical Systems Department at the study site had implemented various forms of an EHR documentation for nursing and was aware of some existing problems and … And they serve as a standard form of documentation that can be shared by everyone on the healthcare team. Mo Med. resources.eln.io/gibbs-reflective-cycle-model-1988/, ahrq.gov/workingforquality/nqs/overview.htm, nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf, modernhealthcare.com/article/20130703/blog/307039936, jointcommission.org/assets/1/6/SEA_54_HIT_4_26_16.pdf, hhs.gov/hipaa/for-professionals/special-topics/hitech-act-enforcement- interim-final-rule/index.html, admission medication reconciliation—from 52% to 70%, plan of care appropriate for patient’s chief com- plaint—83% to 100%, plan of care related to patient comorbidities— 30% to 87%. Perspect Health Inf Manag. 2009. hhs.gov/hipaa/for-professionals/special-topics/hitech-act-enforcement- interim-final-rule/index.html. The role of EHRs is becoming increasing influential as more patient information becomes digital and larger numbers of consumers express a desire to have mobile access to their health records. 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