Key health record information to keep track of - Worksheet

What information does an electronic health record EHR contain?

EHRs contain a multitude of information that can differ depending on the needs of your healthcare practice and patients. Because this can be quite complex, many healthcare businesses provide EHR SaaS systems to help with medical billing, appointment scheduling and manage clinical notes in one secure platform. These systems are highly convenient, and can often streamline necessary tasks required by both small and large practices. To help you understand how EHRs work, we have compiled some of the vital information that they contain:

1. Patient identifiers - This includes personal details such as the patient’s full name, date of birth, email address, physical address, phone number, as well as emergency contact information. Often a unique patient ID will also be generated to identify specific patients which makes the data processing much easier if information needs to be retrieved. 
2. Demographics - Any demographic information, such as age, gender, and ethnicity, is also collected and presented in EHRs. This is often used to match patient records across data sources, and there are also treatment and legality purposes for having these details. Occasionally, education and nationality are noted.
3. Diagnoses - The patient diagnosis is one of the most important components to include in EHRs given it is primarily concerned with the patient’s health and condition. By noting the diagnosis, healthcare professionals can easily understand associated symptoms, medications, and treatment plans, as well as what further directions to take. 
4. Medications - Medications are vital to EHRs, as not only is this helpful when making treatment decisions, but it is also important for pharmaceutical claims. Prescriptions always need to be noted to inform therapy and treatment plans, as well as if the patient is referred to another healthcare professional so they are aware of the patient’s current medication.
5. Procedures - This includes clinical procedures such as radiology, surgery, laboratory, and pathology. Recording this information allows all healthcare professionals to understand a patient’s history, as well as the data composing a patient’s medical record that accounts for all medical procedures. 
6. Lab data - Any laboratory data concerning the patient should be included in EHRs, which includes both lab orders and lab results. This is especially important considering that claims may be required for this information in the medical billing and coding process, so the right information can be referred to. 
7. Vital signs - Vital signs are used to regularly assess the patient’s health, and include physiological signs such as weight, height, blood pressure, glucose levels, temperature, body mass index, pulse rate, and respiratory rate. Vital signs are used to evaluate patient condition and work towards an efficient treatment plan based on objective signs and symptoms.  
8. Cost - It’s important to note down the cost as insurance data may not be available, and this is vital for claims and the overall financial health of your business. Recording costs can help you better focus your income efforts on where it is needed and avoid financial waste. 
9. Surveys - Any standardized surveys that are accessed through patient portals need to be recorded in EHRs, particularly in situations where information needs to be accessed by other healthcare providers. The results of surveys are highly informative and can be used when making decisions about further treatment.
10. Social data - This includes details concerning socio-economic status, housing, and smoking conditions, as well as any other elements from the individual to the community level. Note that this information mainly influences research, and not necessarily treatment plans. 
11. Patient data - This can include sleep patterns, blood sugar levels, wearable device data, as well as any physical activity. It is information unique to the patient. 

Best practices for EHR documentation

When it comes to EHRs for your private practice, there are several things you should consider to ensure you are working efficiently and effectively to maintain documentation integrity:

1. Govern information - You must ensure there are proper control and management systems in place when it comes to overseeing your information. Poor data can become extremely problematic down the road if incomplete, untrustworthy, or redundant. 
2. Be legally compliant - As well as being HIPAA compliant, your information needs to meet insurance claim criteria, as well as meet reimbursement policies. Sometimes over-documenting isn’t necessarily a bad thing if it means your data is more likely to be accepted.
3. Don’t copy and paste - Every patient is unique, and therefore every EHR needs to reflect that. Vital signs should not be copied and pasted, even if similar results, because this can lead to immense medical liability issues. 
4. Validate your dictation errors - There should be a correcting process in place to avoid extensive edits and reviews. Errors should be transparent, and other healthcare professionals should know who made them and why.
5. Avoid patient identification errors - The wrong matching of patient information can be highly risky, and affect clinical outcomes and decision making. It also can result in increased costs and can affect patient privacy and security. 
6. Audit - Information should always be checked to ensure consistency, and to fulfill legal obligations. Any changes made need to have a note of who made them, as well as the nature of the amendment. Audit trails are vital to a high-quality EHR. 

Regulations for medical records management

The regulations for medical record management are not set in stone, and can easily change over time. 

The main regulation is the Health Insurance Portability and Accountability Act (HIPAA), as amended by the Health Information Technology for Economic and Clinical Health Act of 2009. It promotes the use of EHRs in a way that is private and secure for patient data and information. It outlines how information needs to be stored and also destroyed, in the case it is no longer needed.

The Medicare Access and CHIP Reauthorization Act (MACRA) is concerned with healthcare in the US, and how it is paid for. Under the Merit-Based Incentive Payments System (MIPS), practices may need a certified EHR system. Note that not all EHR providers are certified, and it could take some time for them to be, hence, the importance of selecting a software that is approved by the MACRA and can be reimbursed. 

These two laws are the main medical record management regulations, however, state and federal laws can also have implications for healthcare businesses. You will need to research this to ensure you are implementing the right systems that not only meet your needs but are legally fit. 

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Further reading:

• Migrating from Paper to EHRs in Physician Practices
• Security Techniques for the Electronic Health Records