Question

Data integrity Subdomain II.H.5 Model policy initiatives that influence data integrity 1. In your current electronic health record (EHR), registration clerks often bypass the diagnosis field. This is a problem, since coders work from a list which pulls that information to be coded. What initiative can you request with your next update to eliminate that problem? 2. If you implement the initiative you identified, will the problem be totally eliminated? Explain your answer. References

Answer 1

1. Initiatives requested to eliminate the problem of electronic clerks bypassing the diagnosis field in EHR with the next update:

a. Entering diagnosis in the diagnosis field should be made mandatory.

b. Penalizing the registration clerk, if he/she forgets to enter data in the diagnosis field should be considered.

c. Regular auditing to prevent any related quality issues and remedies based on the audit report should be implemented.

2. If the above initiatives are implemented, then the problem of electronic clerks bypassing the diagnosis field can be totally eliminated. It should be the next field by default after the Medical Record Number (MRN). Tab order of the software should be changed in such a manner that the cursor comes to the diagnosis field after the MRN. The program should be changed in such a way that it should be impossible to bypass the diagnosis field and enter data in any other field. By penalizing the irresponsible registration clerk, this issue could be kept under check. Regular auditing is the most efficient tool to get rid of any such irregularity, which is made possible by implementing the auditor's recommendations.