Resident validating data entry


09-Feb-2016 03:08

resident validating data entry-56

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Established policies and procedures such as audit functions must be in place to ensure compliant billing.Without safeguards in place, records could reflect an inaccurate picture of the patient’s condition, either at admission or as it changes over time.An accurate information governance program will ensure the accountability of how information is managed and the information’s integrity.HIM professionals consistently identify the following documentation practices as problematic in EHRs.Documentation templates can play an important role in improving the efficiency of data collection, ensuring all relevant elements are collected in a structured format.However, these templates also have limitations: Cloned documentation continues to be a significant problem that creates unnecessary redundancy and at times inaccurate information in the EHR.

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Processes must be in place to ensure the documentation for the health information used in care, research, and health management is valid, accurate, complete, trustworthy, and timely.

Since these documents are often used and exchanged, the importance of accurate and quality documentation in EHR systems is critical.



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