GENERAL POLICY FOR DOCUMENTATION IN AN ELECTRONIC HEALTH RECORD SUBJECT: PURPOSE: Documentation ui!

e"ine# $o% EHR To en#u%e com&"ete' accu%ate an! time"( e"ect%onic )ea"t) %eco%!#*

STAFF GO+ERNED BY THIS POLICY: EFFECTI+E DATE: DATE RE+IE,ED OR RE+ISED: DISTRIBUTION: All persons governed

POLICY: EHR (Electronic Health Record) content shall be in compliance with standards established by JCAHO (Joint Commission on Accreditation of Health Care Organizations) and AH !A (American Health nformation !anagement Association) and shall also comply with re"#irements in third party payment programs or with licens#re re"#irements of special programs$ All patient care doc#mentation will be entered by provider data entry% transcription% #ploading% and doc#ment scanning$ Electronically stored patient information is s#b&ect to the same medical and legal re"#irements as the hand'written information in the health record$ DEFINITION OF TERMS: ($ Health Record ) the chronological doc#mentation (paper or electronic format) of health care and medical treatment given to a patient by professional members of the health care team$ t is an acc#rate% prompt recording of their observations incl#ding relevant information abo#t the patient% the patient*s progress% and the res#lts of treatment$ PROCEDURE: ($ +he health record will contain s#fficient information to identify the patient, &#stify diagnoses and treatment, doc#ment res#lts of care or treatment, describe the condition of patient #pon discharge, and doc#ment instr#ctions to the patient regarding follow'#p care% activity levels% and necessary medications$ -$ Entries m#st be acc#rate% relevant% timely and complete$ .$ rrelevant te/t needs to be omitted$ Concise notes are more readable than lengthy notes$ 0$ Appropriate note titles m#st be matched to note content and the credentials of the a#thor$ +his enhances the ability to find a note more "#ic1ly and easily$ 2$ 3otes m#st be reviewed and signed promptly$ 4$ 5iewing of #nsigned notes is allowed by pharmacy only d#e to the ris1 of clinical decision'ma1ing based on data that may be changed or deleted$ Other limited access to #nsigned notes may be determined by local policy$

6$ EHR #sers m#st respond "#ic1ly to notifications% which prompt them of doc#ments re"#iring a#thentication or additional information$ 7$ +he electronic f#nction of copy and paste m#st be #sed with ca#tion and according to strict and enforceable policy$ (a) 3ever copy the signat#re bloc1 into another note (b) 3ever copy data or information that identifies a healthcare provider as involved in care that he8she is not involved in (c) 9o not copy entire laboratory findings% radiology reports and other information in the record verbatim into a note$ 9ata copied m#st be specific and pertinent to the care provided (d) 9o not re'enter previo#sly recorded data$ :$ A#thentication incl#des the identity and professional discipline of the a#thor% the date% and the time signed$ 3otes made and a#thenticated by health care team members m#st be individ#ally identified either by the #se of the individ#al*s title% or by the appropriate credential designation$ On affi/ed% a#thentication on electronic doc#ments cannot be rescinded or retracted$ (;$ 3o edit or alteration of any doc#mentation or electronic signat#re% which has been completed% can occ#r witho#t approval of the H ! 9irector$ (($ +he a#thor m#st initiate any retraction or rescission of any entry or originating discipline% i$e$% laboratory and radiology are e/amples of disciplines that may initiate retractions or rescissions within their pac1ages$ (-$ An addend#m to a note is made when a healthcare provider deems it necessary to clarify information recorded in the original doc#ment or to add to the original doc#ment$ (a) Addenda are lin1ed to the original created doc#ment, (b) Addenda m#st be a#thenticated in approved manner, and (c) Addenda m#st note be bac1dated$