NURS FPX 8030 Assessment 5 Creation of Policy or Procedure  NURS-FPX 8030 Evidence-Based Practice Process for the Nursing Doctoral Learner

 

Prof. Name

Date

EHR Data Entry Protocols

Purpose

This policy outlines the requirements for electronic documentation within the ambulatory healthcare electronic health record (EHR) system, ISalus. Proper adherence to these protocols ensures accurate and effective documentation that supports patient care, facilitates communication, and aligns with best practices in reimbursement, risk management, and coordination among healthcare teams.

EHRs serve as a legal record and a tool for meeting regulatory requirements for billing, clinical practice, and standards of care. Proper data entry practices are crucial, as EHRs differ from traditional handwritten notes. While they offer tools to streamline documentation, they also introduce potential risks, emphasizing the need for accuracy and attention to detail.

Population Affected by the Policy

This policy applies to all users of the EHR system within the organization, including healthcare providers, nurses, technicians, therapists, and other staff members involved in patient care. The policy benefits patients by minimizing errors and enhancing safety during care delivery. Compliance ensures equitable application, regardless of demographic factors such as age, gender, or race.

Policy Statement

Objectives

The healthcare organization is dedicated to improving patient safety through the implementation of standardized EHR data entry protocols. These protocols aim to:

  1. Ensure the accuracy, completeness, and timeliness of data entered into the EHR.
  2. Reduce the risk of errors associated with improper EHR use.
  3. Provide clear guidelines for data entry, aligned with best practices and regulatory standards.

Training will be mandatory for all employees within 30 days of hire and annually thereafter. Additional training will be provided when significant system updates occur. Compliance monitoring and audits will ensure adherence to the policy.

Table: Overview of EHR Data Entry Protocols

Heading Description Actions
Guidelines Clear expectations for data accuracy, timeliness, and relevance to patient care. Develop detailed instructions for verifying data, double-checking critical points, and ensuring updates.
Training Requirements Comprehensive training for all staff on EHR data entry protocols. Include purpose, application, and troubleshooting strategies during training sessions.
Monitoring and Evaluation Regular compliance audits and evaluations to measure the policy’s effectiveness in improving patient safety. Assess adverse events, patient satisfaction, and data quality to adjust protocols as needed.

Procedure

  1. Training Development and Delivery

    • Office/practice managers will create training programs based on policy guidelines.
    • Training will be delivered before any EHR use to ensure competency.
    • Employees must meet set standards; non-compliance will result in corrective actions.

  2. Data Entry Process

    • Adopt a two-step data entry system: team members validate peer-entered data for accuracy.
    • Limitations include avoiding copy-paste functions except for verified updates to records.

  3. Timeliness and Supervision

    • Notes must be completed and signed within 24 hours.
    • Supervisors will run weekly reports to address deficiencies.
    • Providers retain sole authorship of their notes unless using an approved scribe.

References

Agency for Healthcare Research and Quality. (2018). Patient satisfaction surveys. www.ahrq.gov/patient-safety/settings/primary-care/resources/quality-improvement/patient-satisfaction-survey/index.html

Antonacci, G., Lennox, L., Barlow, J., Evans, L., & Reed, J. (2021). Process Mapping in Healthcare: A Systematic Review. BMC Health Serv Res, 14(21(1)), 342. https://doi.org/10.1186/s12913-021-06254-1

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