Capture and Structure of Health Information – Electronic vs Manual

Health care organizations continue to evolve in the use of electronic formats to capture, structure and facilitate the use of health information. In today’s healthcare environment organizations can range from entirely manual to entirely electronic, with many falling into a category of hybrid documentation which includes both. As a HIM professional you may have a role in ensuring that as an organization moves along continuum from paper to electronic that the documentation in the health record continues to support the diagnosis and reflect the patient’s progress, clinical finds and discharge status.
Hospital Wellness is in the process of working with the EHR vendor they have selected to finalize the electronic data capture tools for health record documentation. You have been asked by the Chief Information Officer (CIO), to lead a team evaluate and make recommendations on the information and flow of documentation for the first set of templates that will be moved from paper to electronic.
The manual documentation record and an electronic version are provided in your text in under Sample Documentation Forms-Appendix A, which can be accessed through your website access code. Assume that the manual version meets the documentation guidelines that your facility requires based on their documentation guidelines. Evaluate the electronic version of these documents for capturing and ease of use of the health information by comparing and contrasting it to the existing manual version. Recommend and support your position on whether the electronic version presented should be accepted by your organization. If you do not recommend the proposed electronic version, prepare a recommendation for what additions/deletions/revisions are needed in order to accept the proposed electronic tool. The following data capture forms/tools are to be evaluated. The “current” manual form is provided first in the list, followed by the electronic. Please prepare a chart or spreadsheet showing you review and recommendations for submission to the CIO.
Admission Record
Physician Orders
Graphic Vital Signs
Medication Administration Record
Laboratory Reports
Operative Report
Surgical Pathology Report
Discharge Summary