Why Are You Passionate About This Project?

We’ve all heard the saying, “If it’s not documented, it didn’t happen.” While it is an age old saying, it reveals one of the biggest issues within healthcare. The issue is not just proper and accurate documentation, but having a documentation that can keep up with the rapidly shifting and changing landscape that is healthcare. “Documentation is critical for patient care, not only because it validates the care that was provided, but also because it shares key data with subsequent caregivers and optimizes claims processing.” (Recognizing the Value of Clinical Documentation Improvement, 2014).

The careful documentation and subsequent billing process within the course of a patient’s care is an important piece within the healthcare system as a whole. Proper documentation in a patient’s chart relating to any service or procedure is not only important for this patient’s future medical care, but for the facility to receive an accurate reimbursement for the services provided. Reimbursement is affected by every department within the hospital. Healthcare is a business in the long run, and inaccuracies within the reimbursement process will affect the financial stability of the hospital. If a department is mismanaging reimbursement data it could result

Computerize provider order entry has had a tremendous impact on improving patient safety and health care outcomes. As a post-operative unit secretary, I often had the wonderful task of transcribing physician orders. I spent more time trying to contact the physician’s to ensure that I understood their handwriting then actually transcribing the order. There were numerous medication errors made through the assumption of transcribed orders. Consequently, computerized provider order entry helped to significantly reduce those risks. However, I have witness computerized provider order entry errors made by clinicians that the system fails to recognize. For example, a patient reported taking an anxiety medication X 2.5mg PO daily upon admission. Four

A HIM professional is trained in the most up-to-date health information and technology, they are trained to work in any healthcare setting, are vital to daily operations, management of health information, and electronic health records. The job of a HIM professional is to ensure that patient records are accurately kept, complete, and private. Being a skilled HIM professional tells an employer that a person is organized and will have the right information on hand when and where it is needed while maintaining the highest standards of data integrity, confidentiality, and security. Becoming a HIM professional means that the professional is versatile and has the skill set to incorporate clinical, information technology, leadership, and management

Although EMR’s may be taking over the medical world, paper medical charts remain the most well recognized form for keeping medical records. There are however some things within paper charts that some medical personnel might argue make it a primitive aspect of the medical field. One argument in itself is that the abundance of paper that is utilized in paper charting doesn’t stand up to the “green” society we aspire to live in today. “Paper charting used to take so long, the papers would always get unorganized, they took up so much room in the nurses’ station and the worst was waiting for a doctor to finish with a chart so I could chart what I needed to” (Brittney Guggino LPN, 2012). Another acknowledged concern with paper medical charts is the illegible handwriting of clinicians, which is a common, longstanding problem. Being unable to read orders clearly creates an added risk when dealing with patients treatments, medications etc. Paper charts may be familiar but they come with many downfalls and it’s these downfalls which may sway a person’s decision in the opposite direction in regards to the

Reducing the incidence of medical error by improving the accuracy and clarity of medical records.

The Institute of Medicine released a report in 1999 titled To Err is Human: Building a Safer Health Care System concerning the number of medical error related deaths. The report states that between 44,000 and 98,000 medical error related deaths occur each year in hospitals across the country (Kohn, L. T., Corrigan, J., & Donaldson, M. S., 2000) In response to this report, the Institute of Medicine released Crossing the Quality Chasm: Health: A New Health Care System for the 21st Century that outlines six aims for the future of the healthcare system: safe, effective, patient-centered, timely, efficient, equitable (Institute of Medicine, 2001). These aims set to establish the quality of healthcare across the country. Quality is defined by the Institute of Medicine as ““the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (2001).

The problem of medical errors, and in particular medication errors, prompts an immediate attention from health care industries as it demands conservative actions from health care providers. Although many health-care providers value the importance of patient safety and quality health care, very few admit their faults at the occurrence of errors that could jeopardize the health of many individuals. “Medication errors represent the largest single cause of errors in the hospital setting, accounting for more than 7,000 deaths annually- more than the number of deaths resulting from workplace injuries.” (Katheen & Mason, 2005). The loss of these lives hold health-care providers and current standards accountable while many other untraceable errors resulting in injuries and disabilities go unnoticed.

Communication is the key to relating in all environments. When communication lines are broken, it makes take in jobs and personal relationship suffer. In medical environment communication is key in running hospital, nursing home and community care providers. With technology our communication has advanced because now we have electronic medical records. Electronic medical records are a way of providing the medical staff and insurance on the patient health information and insurance coverage. As stated by About.com, “This also provide the doctors away to for individual patients, access to good care becomes easier and safer when

After decades of paper based medical records, a new type of record keeping has surfaced - the Electronic Health Record (EHR). EHR is an electronic or digital format concept of an individual’s past and present medical history. It is the principle storage place for data and information about the health care services provided to an individual patient. It is maintained by a provider over time and capable of being shared across different healthcare settings by network-connected information systems. Such records may include key administrative and clinical data relevant to that persons care under a particular provider. Examples of such records may include: demographics, physician notes, problems or injuries, medications and allergies, vital

In the periodical Medical Errors: Where are We Now it says that a study that was conducted showed that only thirty percent of the patients were told about their medical errors. (Mewshaw, White, Walrath. p. 51)

It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).

Ineffective nursing documentation compromises patient safety and can result in serious or even fatal errors. Nursing documentation is essential to practice and is defined as everything entered into a patient’s electronic health record or written in a patients’ record (Perry, 2014). The goal of effective nursing documentation to ensure continuity of care, maintain standards and reduce errors (Perry, 2014). Nurses are accountable for their professional practice which requires documentation to effectively reflect the care that clients receive. The College of Nurses of Ontario (CNO) states that nursing being regulated health care professionals are accountable for ensuring that their documentation is accurate and meets the practice standards (College of Nurses of Ontario, 2009). Effective documentation strategies to reduce errors include; documenting in a timely fashion, using correct abbreviations and spelling, correcting documentation errors appropriately and ensuring that handwriting is legible. The purpose of this paper is to explore these strategies in greater detail with the goal of improving the care nurses provide to their clients to enhance safety.

Reporting errors can strengthen the processes of care and also enhance the quality of care. To effectively avoid further errors that can cause harm to patients, improvements must be made on the incidents or events reported in reporting system. Reporting errors can help the organizations better understand what happened, identify the factors that cause the occurrence of errors or incidents, determine its frequency and predict whether it could happen again and find an intervention to prevent or to

“Computer system facilitate data collection but may increase the potential for entry of incorrect data through input errors” (Hebda, 2013, p.63). Countless errors can be influent the data accuracy and threaten the patient’s safety. Thus, organizations are implementing several measures to decrease the errors and ensure the high quality of data. Therefore, the most important two strategies that are utilized to ensure the accuracy and safety of data entered into information systems used in nursing practice are the education of personal and system checks. All employees must be educated, and education must emphasize the importance of data accuracy, potentially harmful effects of incorrect data and error corrections. The personal must be proficient with information technology and ensure that data content is accurate, complete, and concise. Furthermore, the staff must be competent in appropriate documentation guidelines and standards and practice universal language that is recognizable by all providers. Furthermore, the