Improving Clinical Data Integrity through EHR Documentation

EHR documentation captures critical information about patient visits, tests, and prescriptions. Proper EHR documentation improves your clinical data integrity. But ensuring proper documentation takes commitment to workflows, EHR usability, and training.

You can also improve clinical data integrity by consolidating data from multiple systems. This process is called clinical data conversion. It can help make your patient records more complete and reduce duplication.

Here is how you can improve clinical data integrity through EHR documentation.

EHR Documentation Ensures Complete and Accurate Records

Your NextGen EHR allows your providers and staff to capture information about patient visits in real-time. This includes medical history, symptoms, diagnoses, procedures, medications, and test orders. EHR documentation is the process of recording this data in your EHR system. To get the most out of your NextGen EHR, you will need to develop workflows that integrate documentation into every office visit. You may also need custom templates that help providers and staff enter the right information at the right time. This will help ensure that your clinical data is complete without overburdening providers.

By building documentation into your office visit workflows, you can capture important clinical data and keep your patient records up-to-date. You can also ensure that all diagnoses, symptoms, and medications get incorporated into patients’ records in a timely fashion. Over time, this helps you develop a complete picture of your patients’ medical history and likely needs. With more complete clinical data, you can identify high-risk patients or target outreach to those with the highest needs.

Clinical data integrity is critical for ensuring proper diagnosis and treatment. Your providers need to trust that the information in your NextGen EHR system is accurate and complete. Through training and workflow redesign, you can make EHR documentation a seamless part of patient visits, improving the integrity of your clinical data.

EHR Documentation Prevents Errors and Duplicative Tests

With consistent documentation of patient encounters, you can prevent inadvertent errors. For example, when providers document all allergies, your NextGen EHR will automatically check prescriptions against those allergies. Documenting all past and present medications and diagnoses also allows your EHR to check for interactions or counter-indications.

EHR documentation can also prevent wasteful, duplicative testing. If each test is documented in your EHR, providers will have easy access to prior tests and results before ordering new tests. You can also prevent duplicative testing by utilizing NextGen Share and Carequality to share with other providers. Through clinical data conversion, you can import data from other EHR systems into NextGen. This ensures your providers have a complete record of patient care, including tests conducted and medications prescribed by specialists or other providers.

EHR Documentation Reduces Claims Denials

EHR documentation does more than improve patient care. It can also improve your revenue cycle. Proper EHR documentation of patient visits, tests, and prescriptions will help you get reimbursed faster. Payers frequently deny claims for missing or insufficient documentation. If EHR documentation is built into your patient visit workflow, you can ensure all necessary information is captured at the time of the visits. This prevents costly and time-consuming efforts to update documentation and resubmit claims. Any audits you undertake will also go much smoother with complete EHR documentation. Having complete documentation at your fingertips helps you get paid the right amount the first time.

EHR Documentation Eases Reporting Burdens

As payers shift from paying for volume to paying for value, quality reporting requirements have increased. Many quality reporting programs require extensive clinical data. Clinical data integrity is critical for ensuring your practice receives quality bonuses and is eligible to participate in value-based programs. If your workflows and training emphasize EHR documentation, providers and staff can collect all of the data you need for quality reporting with ease.

Your quality reporting is only as strong as your underlying data. If your practice strives to document visits completely and accurately every time, you can ensure that your quality reporting is accurate and up-to-date. You can use tools like TempDev’s Quality Measures Dashboard to keep track of your performance throughout the year, tweaking workflows as necessary to improve lagging documentation or quality performance.

Improving Clinical Data Integrity through Data Conversions

The 21st Century Cures Act pushed forward interoperability and data sharing goals for practices, hospitals, and other health care entities. With data sharing, your practice has access to important clinical data from the hospitals, specialists, and other providers your patients see. However, this data may not always be formatted for easy input into your NextGen EHR. Clinical data conversions help you get shared data or data from legacy systems ready to import into your NextGen system.

Through a clinical data conversion, you can get all of your patient data in one place. This reduces duplication and helps you have a more complete picture of your patients’ healthcare use and needs. Clinical data conversions will make your data more accurate and complete. This will help you better serve patients, reduce errors, and get reimbursed more quickly.

Converting clinical data is a complex process. External experts, like those at TempDev, can help you consolidate your shared and legacy data into your NextGen EHR.

How TempDev Can Help

TempDev’s team of NextGen experts is ready to help with any of your NextGen EHR needs. Clinical data integrity is important for patient care and your practice’s financial health. TempDev can help you improve your clinical data integrity through:

If your practice is struggling with clinical data integrity, TempDev’s consultants and developers can get you back on track.

Call us at 888.TEMP.DEV or contact us here to get started improving your clinical data integrity with EHR documentation.