Electronic Health Record Policies
Electronic Health Record Policies
(Electronic Health Record Policies)
Electronic Health Records (EHR) policies are crucial for ensuring the effective and secure management of patient information in healthcare settings. These policies typically encompass data privacy, access control, and system interoperability.
Data Privacy: Policies mandate strict confidentiality of patient information, aligning with regulations such as the Health Insurance Portability and Accountability Act (HIPAA) in the U.S. They dictate that sensitive data must be encrypted and stored securely to prevent unauthorized access.
Access Control: EHR systems must implement robust authentication mechanisms to ensure that only authorized personnel can access or modify patient records. This includes role-based access controls and regular audits of user activities.
System Interoperability: Policies promote the seamless exchange of health information across different systems and platforms, facilitating coordinated care. They often require adherence to standardized protocols and data formats to enhance compatibility and reduce errors.
Additionally, EHR policies include guidelines for data accuracy, backup procedures, and user training to ensure that the system supports effective healthcare delivery while safeguarding patient rights. Regular reviews and updates of these policies are essential to adapt to evolving technological and regulatory landscapes.
Health Policy
Scenario: As the recently hired Corporate Director of Health Information Management, you have been tasked the assignment of creating much-needed policies to govern the practice of health record documentation within your organization. You must devise two (2) of these policies, adhering to the format listed below and using APA formatting with sub-headings. Submit one (1) single Microsoft Word document.
Deliverables: Create two (2) policies to address electronic health record documentation. You must select from the following list of topics:
- The Use of Electronic signatures/Authentication
- Legibility
- Electronic Health Record Duplication
- Health Record Amendments
- The Completion of Health Records (adhering to TJC timeline)…including various forms (components within the Health Record such as the History & Physical, Operative Notes, Nurses Notes and Physician Orders etc.)
- Verbal & Telephone Orders
- The use of departmental/organizational wide abbreviations
- The Physician Query Process
- The Use of MACRA & Meaningful Use (MU) Audits
- Authorized Users, including Training & Education and Password Protection and Updates
- Copy & Paste Functionality
- Cloned Documentation
- Templates/Screen Designs
Health Record Policy Format:
- Subject
- Purpose
- Staff
- Effective Date
- A thorough description of the policy
- Definition of Terms (associated with policy)
- Procedure
- Consequences for Failure to Comply
Resources:
Integrity of the Healthcare Record: Best Practices for EHR Documentation (2013 update):
Fundamentals of the Legal Health Record and Designated Record Set:
Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings: http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-20-2015/No2-May-2015/Articles-Previous-Topics/Technology-Safety-and-Professional-Care-Documentation.html
MACRA & MU: http://www.fiercehealthcare.com
Sample Compliance Checklists for Electronic Health Records: https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/ehr-compliance-checklist.pdf
World Health Organization: GUIDANCE ON GOOD DATA AND
RECORD MANAGEMENT PRACTICES: http://www.who.int/medicines/areas/quality_safety/quality_assurance/Guidance-on-good-data-management-practices_QAS15-624_16092015.pdf
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