ReF # KEYWORDS Questions Answer Reviewed by Data or Evidence? Reference/Source Date (Taskforce Member) 5 Error correction What type of It is vendor-specific, but Lisa Bove CHIT Display errors format should is common. Melissa Barthold Audit trail be used to Some systems display it with Jim Cato Format for indicate errors strikethrough, some have the Brenda Kulhanek errors or changed erroneous data display removed Julie Luengas to documentation? from view.( This is configurable.) documentation Should the older data be displayed? Since clinical decisions are based on How is the data, it is important to at least be completed able to see what the prior data was. history of data The clinician needs to know that the configured? data was changed. Can it be configured to one trail) standard? “Error explanations– CHIT standard is Show the original, changes how the date/time of the - and – much should be provided the ability to maintain it. in strikethrough format? Or AHIMA - Especially refers to should it be in physician documentation. Most that format?” physicians have addendums, rather than strikethrough, even on paper. 24 Policy What policies Procedure Policies: Jim Cato Procedures should be All documentation policies should be Brenda Kulhanek Guidelines addressed prior reviewed/revised to accommodate Melissa Barthold Documentation to electronic electronic documentation. documentation Design should take policy requirements into consideration. Should include the following for electronic and documentation: What should be documented, where it should be documented and the frequency the information should be documented. For example, IV catheter, document the gauge, site
ReF # KEYWORDS Questions Answer Reviewed by (Taskforce Member) Data or Evidence? Reference/Source Date 5 Error correction Display errors Audit trail Format for errors to documentation What type of format should be used to indicate errors or changed documentation? Should the older data be displayed? How is the completed history of data configured? trail) “Error explanations– changes – how much should be in strikethrough format? Or should it be in that format?” It is vendor-specific, but is common. Some systems display it with strikethrough, some have the erroneous data display removed from view.( This is configurable.) Since clinical decisions are based on data, it is important to at least be able to see what the prior data was. The clinician needs to know that the data was changed. Can it be configured to one standard? CHIT standard is Show the original, the date/time of the - and provided the ability to maintain it. AHIMA - Especially refers to physician documentation. Most physicians have addendums, rather than strikethrough, even on paper. Lisa Bove Melissa Barthold Jim Cato Brenda Kulhanek Julie Luengas CHIT 24 Policy Procedures Guidelines Documentation What policies should be addressed prior to electronic documentation Procedure Policies: All documentation policies should be reviewed/revised to accommodate electronic documentation. Design should take policy requirements into consideration. Should include the following for electronic and documentation: What should be documented, where it should be documented and the frequency the information should be documented. For example, IV catheter, document the gauge, site Jim Cato Brenda Kulhanek Melissa Barthold