Chapter 9 Test 3 Flashcards
Detract from the chronology of care and increase likelihood of liability
_______ and ______ in time refer to lengths of time when there is no documentation
Gaps and omissions
Spaces left between entries in the health record
Gaps
Require particular attention to objective documentation
Hostile patients
Differing opinions must be documented in the record if pertinent to care
However, documentation should not highlight disagreements
Language must be objective and factual
Staff disagreements
Objective and factual documentation
Documentation should include statements made, identification and thorough description of of injuries, and photos
Injuries resulting from criminal activity
Heightened if documentation is missing, incomplete, biased, critical, and based on opinions rather than fact
Liability for improper entries
Associated with data creation
Emphasis on accuracy and integrity
Data governance
Associated with information after it has been created
Emphasis on safeguarding and protection
Information governance
Genuineness of a record; that it is what it purports to be
Authenticity
Security process that verifies one’s identity and authorizes system access
Authentication
Applying a signature to documentation, showing authorship
EX: Paper records and electronic records
Attestation
Handwritten signatures; initials; rubber signature stamps (not favored)
Paper records
Digitized signature; button, PIN, biometric identifier or token; digital signature (all referred to as electronic signatures)
Electronic records
Attestation by a second provider that signifies review and evaluation of the actions and documentation, including attestation, of a first provider.
Countersignatures
Several staff members complete documents such as assessments at different times, requiring ________. They should sign a date and indicate the sections they completed.
Multiple attestations
When an author can no longer attest to documentation to validate accuracy, like a resign or death, there are alternate signers who are familiar with the case.
Attestation on behalf of another
Occurs when failure of an author to review and actively approve or disapprove an entry in an EHR within a specified time period results in ____
Auto-attestation
Attesting to multiple entries or orders at one time. Acceptable when reviewed and not acceptable when the provider signs the entries or orders without reviewing first.
Batch signing
Person who documents in the health record for the provider. Must be uniquely identified and Provider must attest to the entries upon review.
Scribes
Provides background information about actions that affect creation, revision, and access to data
Metadata
Increase efficiency and structure, but create integrity issues
Documentation templates
Degree to which information in the record reflects what actually happened
Accuracy
Information may be placed on wrong encounter or wrong patient
- Medical Plagiarism
Risks of healthcare fraud when documentation from another provider or another patient’s record is used
Authorship and Cut, Copy, Paste (Cloning)
Using another’s documentation without permission
Medical Plagiarism
Must use only organization-approved ________.
Must not use Joint Commission prohibited ________.
Abbreviations
Physician handwriting
Legibility
Changes should be made ONLY per organizational policy Revisions Late entry Amendment Addendum Removal Version Management
Health Record
Replacing inaccurate information with accurate information after attestation
Revisions
Entry missed or not written in timely manner
Late entry
Information added to support or clarify (HIPAA individual right)
Amendment
New documentation added to original entry after attestation
Addendum
Permanent elimination of information (limited, if permitted at all)
Deletion
Information no longer available for viewing but is available in the background
Retraction
What are two types of removal?
Deletion and Retraction
How an organization handles numerous iterations of a document
If used for patient care, must be retained
Version management
Promptness of documentation
Timeliness
Comprehensiveness of documentation
Mandated by accrediting and licensure bodies
Important from evidentiary standpoint
Completeness
Types of PHRs?
Standalone PHRs
Tethered PHRs
Information provided by the patient, either by paper, computer or thumb drive, or internet repository of their choosing
Standalone PHRs
Connected to a secure electronic portal to an organization’s information system, like an EHR.
Tethered PHRs
