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New Guidelines for Clinical Documentation in the 21st Century

ACP addresses health information technology and informatics

Guidelines have been developed for clinical documentation and interrelated issues. The position paper was published online January 13 in the Annals of Internal Medicine.

Researchers at the American College of Physicians (ACP) in Washington, D.C., developed a policy paper to address issues related to health information technology and informatics in U.S. health care. To improve the quality and value of clinical documentation, the authors developed recommendations for clinicians, provider institutions, technology vendors, government regulators, payers, and other interested groups.

The authors note that the primary goal of electronic health record (EHR)-generated documentation should be “concise, history-rich” notes that reflect the information collected and that are used to formulate a diagnostic/treatment plan and recommended follow-up. Clinical documentation should support patient care and improve clinical outcomes via improved communication, they say, and clinical records should include the patient’s history in as much detail as is required.

Specifically, the ACP’s recommendations for clinical documentation include the following:

  • The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.
  • Physicians working with their care delivery organizations, medical societies, and others should define professional standards regarding clinical documentation practices throughout their organizations. Further, clinical usefulness of health information exchange will be facilitated by appropriate redesign of clinical documentation based on consensus-driven professional standards unique to individual specialties as a result of collaboration with standards-setting organizations.
  • As value-based care and accountable care models grow, the primary purpose of the EHR should remain the facilitation of seamless patient care to improve outcomes while contributing to data collection that supports necessary analyses.
  • Structured data should be captured only where they are useful in care delivery or essential for quality assessment or reporting.
  • Prior authorizations, as well as all other documents required by other entities, must no longer be unique in their data content and format requirements.
  • Patient access to progress notes, as well as the rest of their medical records, may offer a way to improve both patient engagement and quality of care.

The ACP also calls for further research to:

  • Identify best practices for systems and clinicians to improve the accuracy of information recorded and the value of information presented to other users.
  • Study the authoring process and encourage the development of automated tools that enhance documentation quality without facilitating improper behaviors.
  • Understand the best way to improve medical education to prepare new and practicing clinicians for the growing uses of health information technology in the care of patients and populations and to recognize the importance of their responsibility to document their observations completely, concisely, accurately, and in a way that supports their reuse.
  • Determine the most effective methods of disseminating professional standards of clinical documentation and best practices.

Further, the new guidelines include the following policy recommendations for the design of EHR systems to support 21st-century clinical documentation:

  • EHR developers need to optimize EHR systems to facilitate longitudinal care delivery as well as care that involves teams of clinicians and patients who are managed over time.
  • Clinical documentation in EHR systems must support clinicians' cognitive processes during the documentation process.
  • EHRs must support “write once, reuse many times” and embed tags to identify the original source of information when used subsequent to its first creation.
  • Wherever possible, EHR systems should not require users to check a box or otherwise indicate that an observation has been made or an action has been taken if the data documented in the patient record already substantiate the action(s).
  • EHR systems must facilitate the integration of patient-generated data and must maintain the identity of the source.

“We must work together to fundamentally change the EHR from a passive recipient of information to an active virtual-care team member,” the authors write.

Sources: Medical Xpress; January 13, 2015; and Annals of Internal Medicine; January 13, 2015.

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