NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

Student Name

Capella University

NURS-FPX 8030 Evidence-Based Practice Process for the Nursing Doctoral Learner

Prof. Name

Date

EHR Data Entry Protocols

Purpose

This policy and procedure aim to establish requirements for electronic documentation in the ambulatory health care record EHR for the organization.

Principles for Accurate and Effective Documentation

Following the principles below will help ensure accurate and effective documentation in the established EHR – iSalus that will serve patients well and facilitate communication and care coordination. This is considered best practice for reimbursement, risk management, care coordination, and communication among the healthcare team.

Legal and Ethical Considerations in EHR Data Entry

Creating an electronic medical record that facilitates excellence in patient care meeting regulatory requirements, such as billing, clinical practice, necessary use, and standards of effective care, also serves as a legal record. It requires attention to detail and precise and accurate data entry. Legal, ethical, and billing compliance are no different from those governing traditional handwritten notes. However, there are fundamental differences between the EHR and paper records. EHRs have built-in support tools that can be helpful as well as problematic.

Protocols and Standards for Data Entry

The purpose of these protocols and standards is to facilitate an organizational standardized process for data entry and documentation within the facility’s electronic medical record (EMR) based on the following:

Impact of EHRs on Patient Safety

Electronic health records (EHRs) can improve patient safety through access to accurate and up-to-date patient information (Koppel et al., 2016). However, EHRs can also introduce new risks if not used correctly, such as errors in patient care resulting from poor data entry practices (Shim et al., 2019). To mitigate these risks and improve patient safety, we must implement strict data protocols in our healthcare organization.

Supporting Evidence from the Literature

Supporting evidence from the literature suggests that implementing strict data entry protocols can help reduce the risk of errors in patient care (Bates & Gawande, 2017). A systematic review and meta-analysis of the impact of EHR adoption on patient safety found that the risk of errors increased when EHRs were not used properly but that implementing strict protocols for data entry and other interventions aimed at improving EHR usability could help to reduce the risk of errors (Xu et al., 2020).

Clinical Professionalism in EHR Documentation

Clinical professionalism extends to the documentation of healthcare providers’ services – signing the clinical note implies that the provider takes full responsibility for the note’s content. Medical records serve to document the care provided and serve as legal documents. Entries in the EHR should be appropriate, concise, timely, relevant, and pertinent to the patient’s condition on the date the entry was made.

Revised PICO(T) Question

Revised PICO(T) question: In healthcare organizations using EHRs (P), how does the implementation of strict protocols for data entry (I) impact the risk of errors in patient care (O) compared to no intervention (C)? Is this intervention improving patient safety (T) over three months?

Policy Development and Purpose

It is necessary to act with the development of this policy to address the gap or problem in patient safety related to poor patient data entry practices in the organization’s EHR system. By implementing strict protocols for data entry, our healthcare organization can help reduce the risk of errors in patient care and improve patient safety. This policy has been developed based on the evidence from the literature review. It has been designed to address the identified patient safety issue in a systematic, evidence-based manner.

Population Affected by the Policy

The population affected by the policy on EHR data entry protocols includes healthcare providers and other users of the EHR, such as nurses, technicians, therapists, and other end users of the healthcare organization.

Definitions

Electronic health record (EHR): An electronic version of a patient’s medical history, which includes information such as medications, allergies, diagnoses, and test results. EHRs manage and share patient information within healthcare organizations and can improve patient safety by providing access to accurate and up-to-date patient information (Koppel et al., 2016).

Data entry: Entering information into an electronic system, such as an EHR. Data entry can involve transcribing information from paper records, updating information in the EHR, or entering new information into the system.

Protocol: A set of rules or guidelines that outline how a particular process or procedure should be carried out. In the context of EHR data entry, protocols may include guidelines for verifying the accuracy of entered information, procedures for double-checking critical data points, and standards for ensuring the completeness and timeliness of data entry.

Patient safety: The absence of preventable harm to a patient during the provision of healthcare services (World Health Organization, 2018). Patient safety is a critical issue in healthcare and can be impacted by factors such as errors in patient care, adverse events, and medical mistakes (Bates & Gawande, 2017).

Policy Statement

Our healthcare organization is committed to improving patient safety and is implementing a policy on EHR data entry protocols to reduce the risk of errors in patient care. The policy will be implemented within the next three months and applied to all healthcare providers and patients within our organization. The goals of the policy are to ensure that all data entered into the EHR is accurate, complete, and up-to-date and to provide clear guidelines for data entry to reduce the risk of errors. By implementing this policy, we aim to improve patient safety and the quality of care we provide to our patients.

Behavioral Health Program Compliance Training

The behavioral health program’s policy is that all users of the organization attend mandatory compliance training within 30 days of hire annually. When critical updates to the EHR system are made, they may require additional training.

Procedure

Develop Training Based on Policy and Procedure

The office manager/practice manager will develop training based on Practice Policy. Ensure training is delivered in the appropriate format and time frame before any use and documentation efforts in the HER. Ensure all employees complete training and achieve the required level of competency indicated for proper navigation through the required areas of data entry per each level of indicated use. Intercede and take action against any employee that does not meet the required standards of training required.

Guidelines for Data Entry

To ensure that all data entered into the EHR is accurate, complete, and up-to-date, we will develop guidelines for data entry that outline the requirements and expectations for data entry. These guidelines will include specific instructions on verifying the accuracy of entered information, procedures for double-checking critical data points, and standards for ensuring the completeness and timeliness of data entry.

Training for Healthcare Providers

To ensure that all healthcare providers are competent and confident in their use of the EHR and the established data entry guidelines, we will provide training on the guidelines to all healthcare providers. This training will cover the purpose of the guidelines, how to follow the guidelines in practice, and how to identify and address any issues that may arise during the data entry process.

Compliance Monitoring

To ensure that the guidelines are being followed and that the policy has the intended impact on patient safety, Compliance will be monitored with the guidelines regularly. This may involve conducting regular audits of data entry practices, reviewing regulatory regularly racy and completeness, and identifying and addressing any issues that may arise.

Effectiveness Assessment

To determine whether the policy is effective in improving patient safety and reducing the risk of errors in patient care, we will assess the effectiveness of the policy regularly. This may involve collecting data on adverse events related

to EHR use, measuring patient satisfaction with the quality of care, and reviewing the EHR for accuracy and completeness. Based on the results of these assessments, we may make modifications to the policy as needed to optimize its effectiveness.

Electronic Documentation Tools

Data entry and review of the data entered will be completed using the team block data entry method, where after entry of selected data into the patient chart (demographics, insurance information, provider, and care team) will be reviewed by a peer who, in turn, is responsible for validating information has been entered correctly, before compiling this section of the patient medical records.

This two-step process will authenticate that the data entered is correct and concise.

It has been determined that several functions, though capable with this EHR system, have yet to be advocated (such as copy and paste and unauthorized templates).

Copy and Paste should be avoided as much as possible.

Copying another provider’s previous note should be avoided. Copying and forwarding lists (problem lists, allergies, medication records, health maintenance, and immunization records) are acceptable. Be aware that this information should be reviewed and updated by the provider. Lab results should be imported from the laboratory data integrated with the EHR.

Timeliness

Timely completion of medical record entry is required; visit notes should be completed within 24 hours of the patient visit. Notes should be finalized and signed within 24 hours of the service date. The EHR system has a clinical log report that the clinician can review, which will help determine if all notes are completed and signed. (This can aid in compliance for the provider and the data entry person; each section that still needs to be completed will be highlighted and assigned to the employee). The clinical team leader/supervisor will run weekly reports and notify employees and providers of any deficiencies in this area.

Supervision

Providers are required to author their notes except for using an organization-approved scribe. Employees must not share passwords for logging in to the EHR. Providers may not edit or change the content of another provider’s note. Once the note is finalized, an addendum should be used to document additional information or further clarification of services.

References

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NURS FPX 8030 Assessment 5 Creation of Policy or Procedure