Journal of AHIMA - March 2012

time to several hours (often depending on contractual times or departmental goals).

To this end, copy and paste is still a huge challenge in the industry, says Terri Costa, RHIA, CMT, director of HIM and quality at Betty Ford Center.

“;ere is potential for records to get clogged up with the same information multiple times, and there is always the inherent risk of someone copying an error and then duplicating the error throughout the chart,” she says.

Costa recommends a strict copy and paste policy in conjunction with ongoing physician and sta; education.

;e use of e-mail and texting brings its own set of documentation challenges for HIM professionals.

While securing e-mail and text messages may be a top priority for organizations, there are other peripheral concerns, such as the use of protected health information. Organizations should outline policies and procedures and conduct sta; training on the proper use of protected health information in e-mail communication between provider and patient or provider and provider.

E-mail and text messages require a documented retention policy and schedule.

In addition, a well-de;ned process must exist for archiving messages, including a documented retention policy and schedule. Consideration should be given to scenarios where changes are made to the patient’s treatment plan as a result of an e-mail.

All information entered in the health record should enable triggers for work;ows and alerts according to standard organizational protocol. Using copy and paste to document e-mail content in the EHR may not yield the same work;ow results and places data quality at risk.

;e use of texting in healthcare documentation is getting a lot of attention. According to a recent survey of College of Healthcare Information Management Executives, 97 percent of those surveyed allowed physicians to text orders to their nursing sta; and 58 percent said they do not use encryption software. 2 ;ere are privacy and security concerns within this situation due to the lack of encryption, and use of texting language in the health record carries an increased threat to documentation integrity.

Policy and procedure should address all aspects of text usage, including how text information is transcribed from the text message into the EHR with emphasis on providing complete information. Text documentation should contain professional language with no abbreviations or cryptic language for the receiver to interpret.

Clear documentation standards and proper work;ows are the key to ensuring providers document information that is pertinent, timely, and accurate. It is imperative for HIM professionals to educate, implement, and monitor the data capture and documentation requirements. ¢

Notes

1. ASTM International. ASTM E 2117-06 Standard Guide for Identi;cation and Establishment of a Quality Assurance Program for Medical Transcription. West Conshohocken, PA.

2. Dolan, Pamela. “Physician Texting Provides Quick Communication—and an Easy Way to Violate HIPAA.” October 31, 2011. www.ama-assn.org/amednews/2011/10/31/ bica1031.htm.