Question

The content of the health record is guided by various organizations, rules, and regulations. In this topic, discuss standards and guidelines pertaining to health records. A patient's health record is a history of the story of their health status over a period. What is the goal of documentation standards? In the transition from paper to electronic, how have documentation standards changed?

Answer 1

Health Record:

- It is the means that healthcare providers use to collect and store the clinical documentation they create for individual patients.

Standards related to health record content are statements of expected behavior or reference points against which structures, processes, or outcomes can be measured.

Documentation Standards:

- It describes those principles, codes, beliefs, guidelines, and regulations that guide healthcare documentation.
Dictates how healthcare providers should document the treatment and services within the health record.
- They are evaluated conformance with a generally accepted rule.

Goals of Documentation Standards:

- Ensures complete health record and accurately reflects the treatment provided to the patient.
- Provides overall inherent level of acceptable quality.
- Drives appropriate reimbursement through accurate code capture.

In transitioning to EHRs:

- Long term, there are actually cost savings compared to the current paper/manual systems once training has taken place and staff members become more comfortable with the new processes.
- Initial costs are highest when moving to an electronic system.

- Drawback to paper records: It is located in a single location and restricted to one use at a time.

- A national focus on IT and paper record shortcomings forces are advancing the adoption of electronic health record adoption.

- Easy assess, time saving, maintaing up-to-date knowledge of quality and cost incentives encourages the adoption of the electronic system. Thus with this documents standards changed.