Improving Clinical Data Integrity through EHR Documentation

What You Need to Know (2021)

In this article, we will cover everything you need to know about the role of EHR documentation in improving clinical data integrity.

Overview

Over the past few years, technology has done wonders in the field of medical record documentation. The process became faster and more convenient, which indirectly improved patient care.
Electronic health records (EHR) that allow for easy access to a patient’s data removed the need for traditional paperwork in a physician’s office. However, when speed is involved, the risk of making errors during input is always present.
For this reason, it is crucial to maintain the integrity of the data when using EHR documentation. This process ensures that the patient records are accurate and safe to avoid errors during medical care. You see, when medical decisions stem from erroneous data, they can potentially lead to devastating consequences.

Clinical Data Integrity

What Is Data Integrity in Healthcare?

Clinical data integrity describes the accuracy and consistency of data throughout its life. Differently put, it describes the process of maintaining data in an organized and accurate fashion.

Numerous ways could lead to the corruption of data integrity. As a result, you may find disparities between the physician’s original notes and the ones found on the patient’s EHR.

Why Is It Important in Healthcare?

Data integrity is of extreme importance since it identifies and tracks patients as they move through different levels of healthcare. It ensures that every patient is receiving the appropriate care that matches their symptoms and past medical history. It will also support the process of billing patients.

To demonstrate the vitality of clinical data integrity, let us take a real-life example of what could go wrong.

On September 1, 2013, a physician received a patient just before lunch. After examining the patient, the physician could not enter his note into the patient’s EHR due to the busy workflow.

AHIMA published a 2013 update to its EHR Documentation Guidelines, Integrity of the Healthcare Record: Best Practices for EHR Documentation.

We should note that during this visit, the patient discussed a possible reaction to the prescribed medication. 

On September 5, 2013, the physician returned to duty after a prolonged weekend; he then realized that he did not make the entry of the previous patient on September 1, 2013.

After documenting the patient’s notes, the physician decided to register the data to the previous date (September 1). Following this step, he proceeded to document the patient’s records as good as he could. He also remembered to document the patient’s possible reaction to the prescribed medication.

When another doctor reviewed the patient’s records, he noticed the new note. This doctor worked during the weekend and did not recall seeing this information on the displayed date. To make matters worse, the second doctor prescribed the medication to trigger a severe reaction in the patient during the weekend.

Female doctor working with laptop computer in her office for electronic medical record

How does an EHR help improve data quality and integrity?

Today, many EHR documentation systems provide a comprehensive and consistent review of the patient’s medical records. For instance, if you note a patient’s allergy to a particular substance, the software will check all prescriptions against the documented substance. Additionally, processing all past and present medications, diagnoses, and medical history allow the system to check for interactions and counter-indications, minimizing errors.
Moreover, physicians often get exhausted by time-wasting tasks, such as entering the same information twice, increasing the risk of human errors.
Fortunately, EHR removes this obstacle, allowing doctors to focus more on patient care and less paperwork. Another example includes full access to the patient’s past tests before ordering new ones. This could serve as a great addition to provide comprehensive care for the patient.

Learn more about the other benefits of implementing an EHR system 

New systems of EHR allow doctors to share medical information and receive data from other EHR systems. Of course, this all occurs while ensuring patient privacy.
The process of transferring data from one format to another is known as clinical data conversion, which requires a significant amount of data mapping to ensure data integration during the transfer.
Many healthcare organizations struggle with clinical data conversion as it is not often something done within the organization.

Frequently Asked Questions (FAQs)

  • How do you ensure data integrity?
    Ensuring clinical data integrity is a complex process that involves the cooperation of the healthcare administration with physicians. Allowing technology to be integrated into this field lowers the risk of human errors and facilitates transferring data from one level of healthcare to another.
  • What is data integrity in EHR?
    Maintaining a piece of information intact and unaltered, regardless of how it gets replicated through the organization’s system. All copies of the original data should be perfect replicates.
  • What are the types of data integrity?
    There are mainly four types of data integrity:
  1. Domain Integrity
  2. Entity Integrity
  3. Referential Integrity
  4. User-Defined Integrity

These types refer to different steps of accepting, storing, and sharing clinical data within EHR.

Software FAQ
Interoperability

Takeaway message

Prioritizing clinical data integrity should be of utter importance for physicians and administration workers in the field of healthcare. Several ways could potentially cause data disparities, leading to undesirable outcomes – in some cases, they could be life-threatening situations.

We hope that this article managed to highlight the importance of clinical data integrity through EHR documentation. If you still have any questions, please do not hesitate to share your thoughts or reach out to us by clicking on this link 

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