1

AHIMA Standards Task Force

Information Governance Standards Project

Specification of Checklists and Use Cases for

AHIMA Information Governance Principles for Health Care
(IGPHC)

Chicago, Illinois, USA

2016
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Table of Contents
Synopsis ........................................................................................................................................................ 3
Specifications of HIM Checklists and Use Cases ........................................................................................... 7
Patient Registration .................................................................................................................................. 7
Copy and Paste........................................................................................................................................ 11
Record or Data Quality............................................................................................................................ 15
Patient Matching..................................................................................................................................... 19
Transition of Care.................................................................................................................................... 20
Conformity Assessment .............................................................................................................................. 21
Appendix 1. Glossary of Terms ................................................................................................................... 22
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Synopsis
Overview
Built upon the established collaboration with the Integrating the Healthcare Enterprise (IHE) – a
collaborative of health information technology (HIT) vendors, users and associations of healthcare
professionals to develop interoperability standards – AHIMA has been working with vendors of
electronic health records (EHR), other health information systems (HIS) and health information
technology (HIT) applications guiding the development of functional standards to support health
information management (HIM) practices in electronic environments.

To address user needs with HIT adoption, AHIMA has been leading the development of best practices
and guidelines for information management and information governance as a part of a new globally-
focused AHIMA initiative on Information Governance (IG).1,2 The IG initiative provides an organization-
wide framework for managing information throughout its lifecycle, while, supporting the organization’s
strategy, operations, regulatory, legal, risk, and environmental requirements. The AHIMA IG Initiative –
a key component of AHIMA's overall strategy to develop guidelines, operating rules and standards for
healthcare documentation practices – served as a foundation for the AHIMA-IHE collaborative activities,
which resulted in publication of the AHIMA-IHE white paper “Health IT Standards for HIM Practices”
(http://qrs.ly/lb4vec0) in 2015.

This document specifies HIM Checklists and Use Cases for the selected business requirements specified
under the eight AHIMA IG principles in health care (IGPHC) such as information availability, integrity,
protection, accountability, transparency, compliance, retention and disposition. Business requirements
under IGPHC principles were specified in the AHIMA Specification of Business Requirements for
AHIMA Information Governance Principles for Health Care published in August 2016 (URL: xxxxx).

Table 1 shows AHIMA efforts for specifying HIM Checklists and Use Cases completed in 2015 as a part
of the AHIMA-IHE white paper as well as the 2016 effort of the AHIMA Standards Taskforce.

Table 1. HIM Checklists and Use Cases for HIT Standards

Use Cases for HIT Standards
2015 AHIMA-IHE White Paper 2016 AHIMA Specification
1. All documents in the episode of care record are 6. Copy and paste
accounted for 7. Record and data quality
2. Episode of care record is complete and closed 8. Patient registration
3. Release of Information (ROI) to external 9. Patient matching
requestor 10. Transition of care
4. Audit for the episode of care record
5. Audit for the ROI

1
American Health Information Management Association (AHIMA). Information Governance Principles for
Healthcare (IGPHC). Chicago, IL. 2014. URL: http://www.ahima.org/~/media/AHIMA/Files/HIM-
Trends/IG_Principles.ashx AHIMA thanks ARMA International for use of the following in adapting and creating
materials for healthcare industry use in IG adoption: Generally Accepted Recordkeeping Principles® and the
Information Governance Maturity Model. www.arma.org/principles. ARMA International. 2013.
2
Cohasset Associates and American Health Information Management Association (AHIMA). Professional Readiness
and Opportunity. Information Governance in Healthcare White Paper. Minneapolis, MN. 2015. URL:
http://www.ahima.org/~/media/AHIMA/Files/HIM-Trends/IGSurveyWhitePaperCR_7_27.ashx?la=en
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Specification of HIM Checklists and Use Cases is a part of the collaborative informatics-based approach
for translating HIM practices into HIT standards that was deployed in the 2015 AHIMA-IHE White paper.
This approach of guiding the development of HIT standards to support HIM practices is shown on Figure
1 below.

Approach

IG Principles in Healthcare | Use Cases for Standards

Figure 1. Approach for Guiding the Development of HIT Standards to Support HIM Practices
(Source: AHIMA-IHE White Paper, 2015)
Target Audience
This specification is targeted to
1. Organizations (e.g. healthcare organizations, public health agencies, payers/insurance
companies, academia) involved in origination, management, and use of healthcare data
2. Health professionals that originate, manage, and use healthcare data
3. Implementers - Organization’s staff involved in implementation of HIT Systems
4. HIT vendors and consultants involved in the design, development and implementation of HIT
systems
5. Health information exchange (HIE) entities that collect, manage, and exchange data
6. Standards developers at various standards development organizations (SDOs)
7. Consumers (e.g. patients, care givers, employees, employers) involved in creation, management,
and use of healthcare data and
8. Educators involved in HIT, HIM and informatics training.

In 2016, we are focusing on target audiences #1 and 2.

Scope
This specification is applicable to all health information (clinical, financial and operational), on all media
and formats, created by a healthcare organization in its enterprise information management system.
This includes legal health records and information contributed by patients.

Development Process
HIM Checklists and Use Cases have been developed based on the analysis of the selected business
requirements specified in the 2016 AHIMA Specification of Business Requirements (currently under
public review) as well as literature review of the best HIM practices related to documentation
management. The business requirements originally derived from the description of business processes,
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i.e., statements, provided by each principle in the 2014 AHIMA’s Information Governance Principles for
Healthcare (IGPHC)3 white paper.

The AHIMA Standards Taskforce of subject matter experts (SMEs) conducted thorough review of each
checklist and use case in consensus-based discussions. In addition, the requirements were reviewed by a
broader audience of HIM professionals and other stakeholders as part of the public comment period.
Finalized statements were further used to harmonize the requirements with the AHIMA Information
Governance Adoption Model (IGAM),4 allowing that organizations interested in the IGAM assessment
could prove that each requirement has been met.

Glossary
Glossary of terms was developed in the 2015 AHIMA-IHE White paper. In 2016, we continued to update
the glossary as a separate document. We are also in the process of uploading our terms into the
Standards Knowledge Management Tool (SKMT, URL: http://www.skmtglossary.org/) – an international
Joint Initiative for Global Standards Harmonization Health Informatics Document Registry and Glossary.

Resources
Actors
Table 1 contains the list of actors that is used across various HIM Checklists and Use Cases. This list
includes both Business Actors (users) and Technical Actors (information systems and HIT application).
This separation between business (humans) and technical (information systems) actors is important to
align actors specified in the HIM Checklists and Use Cases with the applicable technical actors from the
IHE interoperability standards, e.g., Content Creator (information systems that acts as information
sender) and Content Consumer (information systems that acts as information receiver).

Table 1. HIM Checklists and Use Cases: Business and Technical Actors
Actors Roles
Business Actors
Primary users:
 clinical care professionals deliver direct patient care
 public health professionals involved in direct patient care
Secondary users :
 health information management information management (capture, validation, retention, etc.)
staff
 compliance staff
 billing staff
 regulatory staff
 legal staff
 insurance carriers
 researchers clinical research, healthcare services research, etc.
 public health professionals public health surveillance, policy and assurance

3
American Health Information Management Association (AHIMA). Information Governance Principles for
Healthcare (IGPHC). Chicago, IL. 2014. URL: http://www.ahima.org/~/media/AHIMA/Files/HIM-
Trends/IG_Principles.ashx AHIMA thanks ARMA International for use of the following in adapting and creating
materials for healthcare industry use in IG adoption: Generally Accepted Recordkeeping Principles® and the
Information Governance Maturity Model. www.arma.org/principles. ARMA International 2013.
4
American Health Information Management Association (AHIMA). Information Governance IQ, URL: IGIQ.org
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Technical Actors
Health Information System (HIS)
Electronic Health Record (EHR)
Laboratory Information
Management System (LIMS)
Clinical Imaging System
Pharmacy Information System
Public Health Information System
Health Information Exchange (HIE)
Patient Portal
mHealth Application

References
Each HIM Checklist and Use Case section contains references to the materials used in their
development.

Document Structure
Sections that follow provide specifications of HIM Checklists and Use Cases. Each section presents
requirements using the following outline:
 Business Requirements
 Definitions
 Actors (business, technical)
 Problems
 Solutions
 HIM Checklist
 HIM Use Case
 Conformity Assessment
 References
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Specifications of HIM Checklists and Use Cases

Patient Registration
Business Requirements
TO BE ADDED – Harry and Diana will add the list of re

Health Information ……….: Business Requirements

Health Information ……..: Business Requirements

Sections that follow were developed using materials from Southern Illinois Healthcare,5 Carbondale,
Illinois; National Association of Healthcare Access Management (NAHAM); 6 National Billing Association
(NBA);7 Joint Commission;8 National Unified Billing Committee (NUBC)9 and National Unified Claim
Committee (NUCC);10 National Compliance Association (NCA);11 Emergency Medical Treatment Act
(EMTA);12 -- other, please add

Definitions
Patient registration is the process to …. It includes the following activities – get steps and definitions
from NAHAM:
1. Scheduling
2. Activating a patient that was scheduled
3. Utilization
4. Patient’s insurance verification
5. TBD

Add registration workflow model diagram here

Actors (business, technical)

Table 1. HIMS Checklists and Use Cases: Business and Technical Actors – ADD Actors and their roles
Actors Roles
Business Actors

5
Southern Illinois Healthcare, Carbondale, Illinois
6
National Association of Healthcare Access Management (NAHAM)….
7
National Billing Association (NBA)….
8
Joint Commission….
9
National Unified Billing Committee (NUBC). URL: http://www.nucc.org/
10
National Unified Claim Committee (NUCC). URL: http://www.nucc.org/
11
National Compliance Association (NCA)…
12
Emergency Medical Treatment Act (EMTA)…
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Primary users:
 clinical care professionals deliver direct patient care
 patient
 caregiver
Secondary users :
 health information management information management (capture, validation, retention, etc.)
staff
 compliance staff
 billing staff
 regulatory staff
 legal staff
 insurance carriers
 researcher???
Technical Actors
Health Information System?
Patient Registration Module?
Billing Information Systems?
Electronic Health Record (EHR)
Patient Portal
mHealth Application

Problems
TBD

Solutions
TBD

HIM Checklist
TBD

Generic Workflow
Get from NAHAM? or elsewhere

Add registration workflow model diagram here

Scope

Activities - TBD
1. Scheduling,
2. Activating a patient that was scheduled

Facilities – Darice will provide the list

1. Inpatient, acute care only – focus in 2016
2. Outpatient
3. ED
4. Hospice
5. Long-term acute
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6. Telemedicine?

HIM Use Cases – Harry will develop one for acute care for TF review

Use Case Name: Patient Registration – Outpatient Visit Scheduled via Call or in Person
Business Actors: Patient, Registrar Staff
Actors
Technical Actors: EHR system, Patient Portal, mHealth application
# of Step Workflow Steps Record, Documents and Data
Scheduling
1 Patient calls/comes to clinic to schedule a visit Pt demographics (name, DoB, address,
2 Registrar staff schedules the visit Insurance ID)
Visit demographics (clinic name,
provider name, date, time)
Reason for visit
3 Registrar staff validates patient information and Same as above
assembles record for the visit New visit record is open
Patient Visit
4 Patient comes to the clinic
5 Registrar staff asks patient to complete medical Medical Summary , Consents
summary information and consents
6 Registrar staff enters updated patient Updated visit record
information and assembles record for the visit
7 Registrar staff sends visit record to clinician Updated visit record
Entry Condition EHR - registration
Exit Condition EHR - triage
Quality reqs Real time patient information verification

Use Case Name: Patient Registration – Outpatient Visit Scheduled Online

Business Actors: Patient, Registrar Staff
Actors
Technical Actors: EHR system, Patient Portal, mHealth application
# of Step Workflow Steps Record, Documents and Data
1 Patient schedules visit using patient portal or Pt demographics (name, DoB, address,
mHealth application Insurance ID)
Visit demographics (clinic name,
provider name, date, time)
Reason for visit
2 Registrar staff is notified about scheduled visit Notification about scheduled visit
completed via patient portal or mHealth
application
3 Registrar staff validates patient information and New visit record is open
send confirmation to patient regarding scheduled Confirmation about scheduled visit
visit via patient portal or mHealth application
4 Patient comes to the clinic
5 Registrar staff asks patient to complete medical Medical Summary , Consents
summary information and consents
6 Registrar staff enters updated patient information Updated visit record
and assembles record for the visit
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7 Registrar staff sends visit record to clinician Updated visit record

Entry Condition Patient Portal, mHealth application and EHR-registration
Exit Condition EHR - triage
Quality reqs Real time patient information verification

References
TBD
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Copy and Paste

Business Requirements

Health Information Integrity (I): Business Requirements

I-16. Ability to establish parameters for “enable / disable” capabilities for “copy and paste” in HIT
product.
I-17. Ability to track “copy and paste” usage (e.g., via color coding, flags, notes, and/or using other
visual identifiers), so information from a previous entry is identifiable and viewable in a subsequent
entry, as well as presented in a complete chronological sequence within a single episode of care. This
will include maintaining metadata on “copy and paste” usage in a data audit of the use of “copy and
paste” function including the source, date, time, author of performing copy and paste.

Health Information Compliance: Business Requirements

C-8. Ability to develop internal controls to monitor adherence to rules, regulations, and program
requirements, thus assessing and ensuring compliance

Sections that follow were developed based on the AHIMA Copy Functionality Toolkit – A Practical Guide:
Information Management and Governance of Copy Functions in Electronic Health Record Systems. 2011.
URL: http://bok.ahima.org/doc?oid=105646

Definitions
The term copy means any one of the following synonyms: copy and paste, cloning, copy forward, re-use,
carry forward, and save note as a template and any intent to move documentation from one part of the
record to another.

Actors
ADD specifics from Table 1. HIMS Checklists and Use Cases: Business and Technical Actors

Problems
Problems (risks) to documentation integrity of using “copy and paste” capability include:
• Inaccurate or outdated information on the patient that may adversely impact patient care
• Information on the wrong patient that may adversely impact patient care
 Redundant information, which causes the inability to determine current information
• Inability to identify the author or intent of documentation
• Inability to identify when the documentation was first created
• Inability to accurately support or defend evaluation and management (E/M) coding for
professional or technical billing notes
• Propagation of false information
• Internally inconsistent progress notes
• Unnecessarily lengthy progress notes

Solutions
Utilization of “copy and paste” capability in health information systems is based on:
• Organizational acceptable uses
• Operational processes and checklists
• Documentation guidelines – what are they?
• Responsibility – Which One?
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• Auditing and reporting

• Sanctions

Business Requirements #I-16 and #C-8

Checklist: Ability to Establish Parameters for “Enable /Disable Copy & Paste” Action
• Define organizational policy for copy & paste action by
 Specifying clinical documentation in which copy & paste action can be performed
 Specifying actors (business and technical) responsible for performing copy & paste
action
 Specifying audit procedure and documentation for performed copy & paste action
 Specifying training procedure for the personnel involved in performing and auditing
copy & paste action

Business Requirements #I-17and #C-8

Checklist: Ability to Perform and Track “Copy and Paste” Usage by HIT Users
• Perform copy & paste action by
 Coping necessary section(s) in the original document
 Pasting necessary section(s) into the new document
 Verifying copied/pasted section(s) between the original and new documents by
providing electronic signature and date/time stamp of completed action
• Identify copy & paste action retrospectively by
 Viewing highlighted copied text in the original document
 Viewing highlighted pasted text in the new document
 Identifying/tracking the identification numbers of the original and new documents
 Identifying/tracking the actors (business and technical) of the original document
 Business actor: name, role, signature
 Technical actor: system name and ID
 Date/time stamp when the original document was created
 Identifying/tracking the actors (business and technical) who performed copy& paste
action (name, role, signature) and where the action was performed
 Business actor: name, role, signature
 Technical actor: system name and ID
 Identifying/tracking the date and time of the performed copy& paste action
 date/time stamp
• Generate the audit log of copy & paste actions in real time by specifying
 The name of actor performing the copy function
 Business actor: name, role
 Technical actor: system name and ID
 What information was copied
 The original document information was copied from
 The new document where information was pasted to
 Date/time when the action was performed
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Scenarios
The following case scenarios demonstrate the appropriate use of copy & paste action.

CASE SCENARIO 1
A 65-year-old woman is a direct admission from her primary care physician (PCP) for pneumonia. She is
admitted to the hospital under the care of her PCP to a general medicine floor. The PCP documents an
extensive history and physical examination in the HER and orders the appropriate tests. On day one of
the hospital stay, the physician completes a progress note. On subsequent days two and three, the
physician completes progress notes updating the patient’s progress and documents the results of all
tests. On day four, the patient is discharged home. The PCP copies forward the chief complaint and
physical examination from the progress note on day one. The PCP indicates that the information is
copied by inserting quotation marks around the documentation and noting “copied from day 1 note.” He
notes on the final progress which phrases have been copied forward and then adds new content
underneath.

Result: The physician appropriately used the copy functionality.

CASE SCENARIO 2
Jane Doe presents to a hospital emergency room for a laceration. While washing dishes this 35-year-old
female cut her hand on a knife in the dishwater. She presents to the ED, is triaged, and moved to
examination room 1. Following evaluation from the physician, the patient receives 10 sutures with
instructions to follow up in 10 days for suture removal. The physician documents his emergency room
encounter for this visit, including a complete history and physical and system evaluation. In 10 days the
patient returns with no complaints, and her sutures are removed. The physician examines the patient
and finds no signs of infection and instructs the nurse to remove the stitches. The physician then pulls up
his prior ED note, highlights the history and physical and system evaluation sections, and copies that
information into the new visit history. The ED coder reviews the documentation and bills for a Level 5 ED
visit.

Result: The first visit was reported consistent with facility E/M guidelines. However, the second
encounter was inappropriately reported at the same level as the first visit because the physician pulled
forward documentation of services that were not actually performed on the second encounter. The ED
coder could not determine that the documentation within the record was from a previous encounter.

What should have happened? If the physician utilized the copy functionality the physician should have
noted the original source document and updated the note with the specific information from this
encounter. System functionality would allow the user to confirm that the physician copied an entry. The
ED coder would recognize the information that was pulled forward, and could then establish the ED
level for the second encounter based appropriately on the services performed during that encounter
only.

CASE SCENARIO 3
A 55-year-old male is admitted through the emergency department of a large academic medical center
following a motor vehicle accident. The patient is admitted to the intensive care unit for a left temporal
bone fracture, left femur fracture, grade-2 spleen laceration, and multiple cuts and bruises. In the course
of his hospital stay, the patient is followed by the trauma service, neurosurgery service, and orthopedic
service, all of which have attending physicians, residents, and physician assistants in addition to medical
students. The patient remains in ICU for five days before he is transferred out to the surgery unit to be
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followed by the trauma service. During his stay in ICU, the trauma medical student initiated daily
progress notes for the trauma service, which were expanded upon by the trauma resident and physician
assistant within the electronic record. Each progress note was then co-signed by the attending physician.
The orthopedic medical student copied forward diagnostic information from the previous day’s
documentation, added new documentation and then forwarded it to the orthopedic attending for co-
signature. Both wrote new progress notes each day, which were signed by the attending physicians. The
neurosurgery medical student used the copy functionality to copy the neurosurgery progress note from
the previous day and add his follow up. The neurosurgery resident simply added his information below
the medical student’s. The attending co-signed each note without noticing that the student had used
copy functionality and selected a level of service based on the entire note.

Result: The trauma service was writing new notes each day that were then co-signed by the attending
service. No documentation issues were identified. The orthopedic service used copy functionality to
bring forward diagnostic information only. In addition to this diagnostic information, the medical
student and resident wrote different clinical information and updates. The orthopedic attending co-
signed each note; therefore no documentation issues were identified. The neurosurgery service,
however, used copy to pull forward information from the initial progress note, thus implying that the
neurosurgery service was providing the same level of detail in the examination on subsequent visits as
on the initial visit. If that is not in fact occurring, the neurosurgery service may be at risk for fraud
related to the level of service.

What should have happened? The neurosurgery service should have indicated which information was
pulled forward from previous notes and which information was new information. The attending
physician is ultimately responsible for the progress notes within the patient record and should ensure
that any resident utilizing copy functionalities has been adequately trained in a manner consistent with
organizational policies
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Record or Data Quality

Business Requirements
TO BE ADDED

Sections that follow were developed based on Brenski A,Dickson B, Adhikari S, et.al. Principles of
Documentation. Electronic Health Record. WHERE. February 29, 2012

Definitions
The medical record serves as the principal repository of data and information about health care services
delivered to a patient. It is a tool in communication to all clinicians involved in the care of a patient. As
such, documentation should be a concise depiction of patient acuity, services rendered, medical
necessity and outcomes. This should include pertinent facts, findings and observations about a
patient’s care delivery, providing a clear picture of services delivered. It is the responsibility of every
individual documenting in the medical record to provide accurate, timely and appropriate
documentation in the medical record. Principal functions of the medical record are:
1. A service documentation tool with information constituting a permanent account of the
services a patient received during an established encounter whether virtual or in person.
2. A communication tool for all care providers with concise, complete and accurate information.
3. A diagnostic tool providing a consolidation of clinical information aiding the care provider in
making informed decisions regarding the patient’s treatment plan.
4. A patient safety tool providing a means for the care provider to assess potential risks to a
patient’s health and well being.
5. A discharge planning tool promoting appropriate follow up care upon discharge.

Medical record quality is ….

Maintain medical record quality is the ability to capture relevant information in a concise and complete
manner while avoiding redundancy.

Data quality is …

Maintain data quality is the ability to….

Actors

Actors Roles
Business Actors
Primary users:
 clinical care professionals deliver direct patient care
 public health professionals involved in direct patient care
Secondary users :
 health information management information management (capture, validation, retention, etc.)
staff
 compliance staff
 billing staff
 regulatory staff
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 legal staff
 insurance carriers
 researchers clinical research, healthcare services research, etc.
 public health professionals public health surveillance, policy and assurance
Technical Actors
Health Information System (HIS)
Electronic Health Record (EHR)
Laboratory Information
Management System (LIMS)
Clinical Imaging Systems
Pharmacy Information Systems
Public Health Information Systems
Patient Portal
mHealth Application

Problems
Today, both HIM professionals and clinicians have been experiencing overwhelming challenges with
usability of the electronic health records (EHR) systems due to shortcomings in supporting user
needs.13,14,15,16, A five-year study recently published by the US National Institute of Standards and
Technology (NIST), on usability of EHR systems17 identified the following four issues with adoption that
may negatively impact patient safety:
1. Clinically relevant information is not available at the task at hand
2. Inadequate documentation
3. Inaccurate information and
4. Irretrievable information.

Solutions
The overall HIM Quality Use Case is focused addressing challenges ##2-3 identified in the NIST report. It
consists of two use cases:
1. Use Case 1: Maintaining adequate documentation (record quality) and
2. Use Case 2: Maintaining accurate information (data quality).

Both use cases are focused on the communication between HIM professionals and clinicians addressing
documentation (record) and data quality concerns. These concerns include:

13 Bowman S. Impact of electronic health record systems on information integrity: Quality and safety implications. Perspectives
in Health Information Management. 2013. URL: http://perspectives.ahima.org/impact-of-electronic-health-record-systems-on-
information-integrity-quality-and-safety-implications/#.VU0OLPm6e00
14 Nguyen L, Bellucci E, and Nguyen LT. Electronic health records implementation: An evaluation of information system impact

and contingency factors. International Journal of Medical Informatics. 2014. 83(11): 779-796.
15 Kuhn T, Basch P, Barr M and Yackel T. Clinical documentation in the 21st century: executive summary of a policy position

paper from the American College of Physicians. Annals of Internal Medicine. 2015. URL:
http://scholar.google.com/scholar?hl=en&q=Clinical+Documentation+in+the+21st+Century%3A+Executive+Summary+of+a+Pol
icy+Position+Paper+From+the+American+College+of+Physicians&btnG=&as_sdt=1%2C14&as_sdtp=
16 Bouamrane M and Mair, FS. A study of general practitioners' perspectives on electronic medical records systems in NHS

Scotland. BMC Medical Informatics and Decision Making. 2013. 13: 58 URL:
http://search.proquest.com.library.capella.edu/docview/1399741170?pq-origsite=summon
17 US National Institute of Standardization and Technology (NIST). Technical Evaluation, Testing, and Validation of the Usability

of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for
Standardization. NISTIR 7804-1. URL: http://nvlpubs.nist.gov/nistpubs/ir/2015/NIST.IR.7804-1.pdf
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Business Requirements #I-16 and #C-8

Checklist: Ability to Maintain Record Quality
Patient registration??

Original Entries
1. All entries in the medical record should be made as soon as possible after the observation,
discussion or event, and should indicate the actual date and time of the observation, discussion,
or event.
2. Entries in the medical record should primarily include information which the provider has
obtained directly from the patient, family member, caregiver, or outside medical records
3. Entries need to be specific, factual, and objective, but may contain subjective interpretations.
4. Entries documenting any patient encounter should accurately reflect the patient’s condition at
that time.
5. Other patients’ names should not be referenced in another’s record.
6. The use of abbreviations should be minimized and restricted to those on the approved
abbreviation list. Dangerous abbreviations should not be used. (See dangerous abbreviations
list).
7. Links that pull patient data should only be included when clinically relevant to that encounter.
8. The provider authenticating the note is responsible for the accuracy of the data contained in the
note.

Late entries, clarifications and addenda

9. Late entries, clarifications and addenda are permissible but must be clearly indicated as such at
the beginning of the documentation. These entries must include the date and time the entry
was entered into the record and not when the entry should have been made.
10. Changes in the patient’s condition and treatment plan need to be documented and provide
evidence of follow through regarding patient stability or problem resolution.
11. Relevant communications and attempts at communication with the patient’s family and / or
other care providers should be documented.

Other providers’ information

12. Other providers’ information may be used but must be appropriately referenced.

Consent
13. The process of informed consent for procedures and treatment must be documented in the
record and should include details of risks, benefits, alternatives, and consequences of no
treatment.
14. The process of informed consent for information sharing with primary users (other providers
involved in direct care) and secondary users must be documented in the record and should
include details of risks, benefits, alternatives, and consequences of non-sharing of information.

Discharge Summary
15. The patient’s discharge summary should contain a concise summary of patient’s illness,
treatment provided, response to treatment, condition at discharge, final diagnoses, and
discharge instructions.
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Business Requirements #I-16 and #C-8

Checklist: Ability to Maintain Data Quality
1. Data entry has to be done….
2. Copying information (e.g. copy and paste, pull forward) from one section of the medical record
to another has inherent risks for medical errors which should be recognized by all providers.

References:
Brenski A,Dickson B, Adhikari S, et.al. Principles of Documentation. Electronic Health Record. WHERE. February 29,
2012
American Health Information Management Association (AHIMA). Copy Functionality Tool Kit. 20082011?. URL:
Be Careful: Copying, Pasting Can Create False EHR Data. Fierce EMR. June 23, 2011
Menzies C. Overview of Copying Notes in the Electronic Medical Record. Personal Communication. August 8, 2011
University of Texas (UT) Southwestern Medical Center. General Medical Record Documentation Guidelines. 2011
Rady Children’s Hospital San Diego. Utilization of Copy/Past Functionality for Documentation within the Electronic
Health Record. 2011
How Original is your EHR? Documentation Integrity Best Practices Webcast. CHCA-What is it? June 2, 2010
Payne TH, EtenBroek A, Labuguen MC. Transition from Paper to Electronic Inpatient Physician Notes. WHERE.
August 23, 2009
Flanagan ME, Patterson ES, Frankel RM, Doebbeling BN. Evaluation of a Physician Informatics Tool to Improve
Patient Handoffs. WHERE. WHEN
Embi PJ, Yackel TR, Logan JR, et.al. Impacts of Computerized Physician Documentation in a Teaching Hospital:
Perceptions of Faculty and Resident Physicians. WHERE. WHEN
Sharp C. Chart Etiquette: Documentation for Integrity and Quality. Stanford Hospital and Clinics. 2010
Wrenn JO, Stein DM, Bakken S, Stetson PD. Quantifying Clinical Narrative Redundancy in an Electronic Health
Record. WHERE. October 26, 2009
American Health Information Management Association (AHIMA). Amatayakul M, Brandt M, Dougherty M. Cut,
Copy, Paste: EHR Guidelines. October 2003
Merrill M. Doc Calls EHR Copy and Paste Function a “Modern Medical Illness”. WHERE. April 23, 2010
Hersh W. Copy and Paste Commentary. WHERE. July/August 2007
American Health Information Management Association (AHIMA). Physician Documentation Practices-an
Unexpected Risk Management Concern. WHERE. October 2008
Dennard J. Nurses Agree: Avoid Copy and Paste in the EHR / EMR. WHERE. April 23, 2010.
 19

Patient Matching
Business Requirements
TO BE ADDED

Sections that follow were developed based on ….

Definitions
TBD

Actors (business, technical)

TBD

Problems
TBD

Solutions
TBD

HIM Checklist
TBD

HIM Use Case

TBD

References
TBD
 20

Transition of Care

Business Requirements
TO BE ADDED

Sections that follow were developed based on the Health Information Technology Standars panel
(HITSP) Interoperability Specification (IS) 09. Consultations and Transfer of Care. URL:
http://www.hitsp.org/InteroperabilitySet_Details.aspx?MasterIS=true&InteroperabilityId=362&PrefixAl
pha=1&APrefix=IS&PrefixNumeric=09

Definitions
TBD

Actors (business, technical)

TBD

Problems
TBD

Solutions
TBD

HIM Checklist
TBD

HIM Use Case

TBD

References
TBD
 21

Conformity Assessment
 22

Appendix 1. Glossary of Terms