The integrity of clinical documentation

Clinical Documentation Integrity:

In the past few years, the healthcare system has experienced constant battle surges between internal and external customers of clinical information to transform medical data into meaningful and beneficial information. The ongoing pressure has emerged from the fact that enterprise-wide systems in the modern healthcare system need high quality data. The quality data is essential to assist in complicated business decision making on a daily basis. While it is vital to enhance the quality and usefulness of medical information, the increase in medical errors has contributed to several concerns regarding the integrity of clinical documentation. Generally, most medical errors in the healthcare system are brought by inadequate, incomplete, and wrong data, especially during documentation. Therefore, healthcare managers should take necessary steps to enhance the integrity of clinical documentation in order to avoid any legal actions and enhance patient outcome through lessening medical errors.

Medical Errors:

The healthcare system increasingly been characterized with the need to enhance quality, useful clinical information in order to improve health information exchange. However, these attempts have largely been affected by the increase in medical errors brought by inadequate, wrong, and incomplete clinical data. Poor quality clinical information affects all healthcare functions by threatening patient safety, impeding patient care, and increasing medical costs. Medical errors also thwart the actual measure of performance, easy healthcare information exchange, and precise research.

The process of ensuring and enhancing the integrity of clinical documentation to avoid such errors is the responsibility of everyone who uses electronic medical records. Actually, insufficient attention to clinical documentation integrity in these records could in turn compromise the usefulness and meaningfulness of medical data for patient care and quality reporting (Miliard par, 2). In light of the increase in medical errors, clinical documentation improvement programs have become necessary in order to lessen these errors and enhance the integrity of the process. Healthcare managers and the healthcare team needs to be assertive and pay more attention to clinical documentation integrity. This process requires the development and establishment of necessary strategies that enhance clinical data and documentation. Without such attention and strategies, there will be an increase in medical errors, which will have tremendous negative impacts on business, compliance, and legal uses.

Steps to Prevent Breaches in Clinical Documentation Integrity:

The process of preventing any breaches in clinical documentation integrity requires increased attention to clinical documentation in electronic medical records. In this case, the healthcare team should support and implement clinical document enhancement plans and growth of clinical documentation integrity programs. Moreover, the team should engage in development and implement widespread data definitions and standards that are applicable across the healthcare facility.

Together with the healthcare manager, the health team should ensure that the adopted electronic health records must adhere to the business requirements for a provider's record of patient care. The electronic health record should have the ability to meet the existing demands for use of information at the medical data and record level. This implies that the electronic health records must have the ability to manage, preserve, and disclose health information in an accurate manner.

Third, more focus should be placed on the quality of data, integrity of information, and good practices of documentation of clinical information to accomplish the policy goals of electronic health records. Given the likelihood of replication of medical errors, it is important for the healthcare team to deal with data quality and record integrity before health information exchanges become widespread. This is primarily because these systems have significantly transformed clinician's workflows and documentation procedures, necessitating sharing of top quality clinical data.

The final step to prevent breaches in clinical documentation integrity is for health information management professionals to help healthcare facilities, the government, vendors of electronic medical records, and other stakeholders to create policies and procedures to promote the collection of accurate material. This will not only help in determining who and when information is entered but also ensure the systems reach their full potential (Miliard par, 13).

Dealing with Breaches of Clinical Documentation Integrity:

Even though more focus and attention to data quality and record integrity in electronic health records help in enhancing clinical documentation integrity, there are still chances for breaches to occur. In such incidents, the healthcare manager should take appropriate measures in order to avoid any legal action and enhance patient outcomes. As a healthcare manager, the first step I would take in care of breach in clinical documentation integrity is to designate a security officer to work with a team of experts in health information technology. Together with these experts, the security officer will inventory the users of the system and the respective technologies in order to identify any security weaknesses and threats. This team will then assign a risk or probability of security concerns in the healthcare facility and deal with them. The process will also involve assigning the responsibilities for the privacy and security of medical information to a member of the physician office staff or even outsource in order to enhance the integrity of clinical documentation (Harman, Flite & Bond p.715).

Secondly, an audit trail program will be developed and implemented in the organization to monitor access to the patient's medical information. These programs track all activities in the system, produce date and time stamps for entries, provide listings of information that was viewed, the duration with which it was viewed, and who viewed it. The significance of audit trail programs in promoting clinical documentation integrity is evident in the fact that they monitor logs of all changes to electronic health records. Moreover, the programs will generate information regarding printed reports, number of screen shots taken, the computer utilized to make requests, and the exact location where such activities were conducted (Harman, Flite & Bond p.716).