General Documentation Guidelines of Health records

General documentation guidelines apply to all categories of health records. These guidelines address the uniformity, accuracy, completeness, legibility, authenticity, timeliness, frequency, and format of health record entries. The American Health Information Management Association (AHIMA) developed the following general documentation guidelines:

• Every healthcare organization should have policies that ensure the uniformity of both the content and the format of the health record. The policies should be based on all applicable accreditation standards, federal and state regulations, payer requirements, and professional practice standards.
• The health record should be organized systematically to facilitate data retrieval and compilation.
• Only individuals (physicians, nurses, physical therapists, and more) authorized by the healthcare organization’s policies should be allowed to enter documentation in the health record.
• Organizational policy and medical staff rules and regulations should specify who may receive and transcribe verbal physician’s orders.
• Health record entries should be documented at the time the services described are rendered.
• The authors of all entries should be clearly identified in the health record.
• Only abbreviations and symbols approved by the organization and medical staff rules and regulations should be used in the health record.
• All entries in the health record should be permanent (written in permanent ink).
• Errors in paper-based records should be corrected according to the following process: Draw a single line in ink through the incorrect entry. Then print the word “error” at the top of the entry along with a legal signature or initials, the date, time, and reason for change, and the title and discipline of the individual making the correction. The correct information is then added to the entry. Errors must never be obliterated. The original entry should remain legible, and the corrections should be entered in chronological order. Any late entries should be labeled as such.
• Any corrections or information added to the health record by the patient should be inserted as an addendum (a separate note). No changes should be made in the original entries in the record. Any information added to the health record by the patient should be clearly identified as a patient addendum (Smith 2001, 56).
• When errors in the EHR are corrected, the erroneous information should not be displayed; however, there should be a method to view the previous version of the document with the original data (Wiedemann 2010).

From a governmental regulatory perspective, CMS and federal regulations also address what would be considered general documentation guidelines and further explain what this guidance means.

• All health record entries must be legible. Orders, progress notes, nursing notes, or other entries in the health record that are not legible may be misread or misinterpreted and may lead to medical errors or other adverse patient events.
• All entries in the health record must be complete. A health record is considered complete if it contains enough information to identify the patient; support the diagnosis or condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among healthcare providers.
• The time and date of each entry (orders, reports, notes) must be accurately documented. Timing establishes when an order was given, when an activity happened, or when an activity is to occur. Entries must be timed and dated for patient safety and quality of care. Timed and dated entries establish a baseline for future actions or assessments and establishes a timeline of events.
• There must be a method to establish the identity of the author of each entry.
• There must be a method to require that each author takes a specific action to verify that the entry being authenticated is his or her entry or that he or she is responsible for the entry and the entry is accurate (42 CFR 482.24(c)(1)).

Authentication is the process of identifying the source of health record entries by attaching a handwritten signature, the author’s initials, or an electronic signature. CMS defines what authentication methods are to be used for health record entries such as written signatures, initials, computer key, or other code; the requirements a healthcare ­provider needs to have in place; and controls to prevent any changes from being made to the health record after the entries have been authenticated (42 CFR 482.24(c)(1)).

Auto-authentication is a procedure that allows dictated reports to be considered automatically signed unless the HIM department is notified of needed revisions within a certain time limit or a process by which the failure of an author to review and affirmatively approve or disapprove an entry within a specified time period results in authentication. For example, a physician dictates an operation, the operative report is transcribed, but the physician never accesses the report to review it for accuracy and completeness. The EHR system is set up to show the physician signed the operative report even though he or she never reviewed the document. Auto-authentication does not meet standards for appropriate timing, dating, and signing-off of documentation by healthcare providers and therefore should not be used.