Documentation Standards of Health records

A standard is a set of principles, codes, beliefs, guidelines, and regulations that have been vetted and agreed upon by an individual or a group of individuals who are regarded as an authority on a particular subject matter. Standards must be based on generally accepted rules of the healthcare industry. Within the context of healthcare, documentation standards describe those principles, codes, beliefs, guidelines, and regulations that guide health record documentation. Documentation standards dictate how healthcare providers should document the treatment and services (rendered to the patient) within the health record. The basis for healthcare-related documentation standards is to promote healthcare quality and safety, as well as provide for optimized continuity of care for the patient. As the health record and health record documentation have become more computer based, documentation standards have become even more important, not only from a clinical documentation standpoint but also from an organizational standpoint. How health record documentation is used within the electronic health record (EHR) has become a focus of many health information management (HIM) professionals.

When the EHR first began replacing traditional paper-based health records, a common belief was that the standards addressing the documentation contained within the EHR (covered in chapter 11, Health Information Technologies) were somehow ­different from those standards addressing the ­documentation in a paper-based health record. This belief is incorrect. In general, the standards that traditionally applied to paper-based documentation hold true for documentation generated and maintained within the EHR. As healthcare providers have come to realize the great benefits of EHR technologies as they relate to documentation quality and overall patient safety, those same technologies have also presented some challenges. One example is the use of a template. A template is a pattern used in EHRs to capture data in a structured manner and specify the information to be collected. For example, a birth record template would require data such as date of birth, time of birth, APGAR scores, length, weight, and so forth. It helps the care provider ensure key information is not forgotten. It also certifies that the data are captured in a specific order and format. Whether the patient’s health record is electronic or paper-based, accurate and appropriate documentation is key to meeting compliance standards—namely, those for medical necessity and the justification for treating the patient.