Importance of Accurate Documentation

Documentation as a nursing intervention is defined as “recording relevant

patient data in a
Clinical record” (Schrefer, et al., 2002:541). It is any written or electronically
generated Information about a patient that describes the care or service
provided to that patient.
Health records may be paper documents or electronic documents, such as
electronic medical Records, faxes, e-mails, audio or video tapes and images.
Through documentation, nurses Communicate their observations, decisions,
actions and outcomes of these actions for Patients. Documentation is an
accurate account of what occurred and when it occurred. It Allows nurses
and other care providers to communicate about the care provided.
The term 'nursing documentation' is used interchangeably with the term 'record keeping' In
the nursing profession. Record keeping is related to the rules and codes of conduct for all
qualified professionals especially when there is a discrepancy among the health team
.how the patient should be treated (Fletcher & Buka, 1999:138
 Documentation allows nurses and other care providers to
communicate with respect to the Care provided.
 Documentation also promotes good nursing care and enables
nurses to meet
Professional and legal standards.They should document who,
when, Where, and why. They should also document the facts only
and only opinions that are Supported by facts. Nurses should
document the objective and not the subjective behaviours, Information
and interventions of the patient.
 An all- inclusive documentation is the most Important tool in
avoiding malpractice, since it can save the nurse and the patient
(College of Registered Nurses of British Colombia, 2007:np and
Ashley, 2004, 75-76).
 The nursing notes provide a comprehensive and regular record of
the care the patient Receives from a nurse. Not only does it
communicate to other healthcare professionals so That continuity of
care is provided for the patient; it is also a legal record that will be
the basis Of the defense in a malpractice court case (Ashley,
2004:75-76).
 It will help them in the scientific evaluation of Patient’s profile,
treatment outcome analysis, and in Planning the treatment
protocols.
 It is also Helpful in planning institutional or governmental
Strategies for future medical care.
 It is Also used to inquire the issue of alleged medical Negligence
during treatment because the legal System relies mainly on
documentary evidence.
 Legal protection
 Quality improvement
 Research and education
 Reimbursement and insurance purposes
(References:- American Nurses Association (ANA) – “Scope and
Standards of Practice” (2020)

INTRODUCTION

An effective health record shows the extent of the health problems’ needs
and other factors that affect individuals their ability to provide care and
what the family believes. What has been done and what to be done now
 also can be shown in the records. It also indicates the plans for future
visits in order to help the family member to meet the needs.

Type of Records

 Cumulative or continuing records

This is found to be time saving, economical and also it is helpful to review the total
history of an individual and evaluate the progress of a long period. (e.g.) child’s
record should provide space for newborn, infant and preschool data.

 Records Maintain in Hospital

A. The patient’s Clinical Record
B. Records of Nurse observation- Nursing Notes
C. Records of Orders Carried out
D. Records of Treatment
E. Records of Admission and Discharge
F. Records of Equipments loss & Replacement ( Inventory)
G. Records of personal performance

 Ward Record

Patient clinical record instruction book, Round register, attendence

register, Drug maintenance register, Admission & Discharge record,
Census record, Call book, Complaint book, Death Register.

 Medical / Nurses Record

Standardized Care plan, Progress Record, Nurses assessment sheet

change of shift record.

 Family records

The basic unit of service is the family. All records, which relate to
members of family, should be placed in a single family folder. This gives
the picture of the total services and helps to give effective, economic
service to the family as a whole.
 Separate record forms may be needed for different types of service such
as TB, maternity etc. all such individual records which relate to members
of one family should be placed in a single family folder.

 FILLING OF RECORDS
Different systems may be adopted depending on the purposes of the
records and on the merits of a system. The records could be arranged

 Alphabetically
 Numerically
 Geographically and
 With index cards
 REGISTERS

 Administrative Record:

Health care administrative data are generated at every encounter with the
health care system, whether through a visit to a physician’s office, a
diagnostic procedure, an admission to hospital, or receipt of a
prescription at a community pharmacy. The terms “health care utilization
data”, “administrative health care billing records”, “administrative claims
data”, or simply “claims data” are synonymous with “health care
administrative data”.

 Physician order sheet and prescriptions:

These are written or dictated notes showing the interaction between the
physician and the patient. These are prepared after an office visit, a
telemedicine visit, testing, a procedure, therapy or other medical
encounter. Accurate physician notes are necessary for the systematic
documentation of a patient’s medical history, present illness, diagnosis,
current and past medications, allergies, treatment, and overall care.
 Nurse’s admission sheet:
An important record in nursing documentation, this admission sheet
documents the patient’s status on admission, reasons for the admission,
and the initial instructions for that patient’s care.
 Nurse’s notes:
These include patient assessment, processes, intervention, and evaluation.
 Medical history and examination:
 It outlines the patient’s medical history, family medical history, social
history, surgical history, allergies, and medications the patient is taking or
has recently stopped taking.
 Emergency room notes:
 These notes summarize a patient’s status during an emergency
department encounter. This would include both narrative and free text
data, and comprises information related to evaluation and plans of care,
chief complaints, physical findings, interventions and outcomes.
 Medication records:
These notes contain details of the medications prescribed, those the
patient has already been taking, and related details. Details include
prescription and non-prescription medication including the dosage,
method of intake, and schedule.
 Mental status report:
This report provides the details of a mental examination, and states
whether the patient is in his/her right mental abilities.
 Operative report:
Operative or surgical reports describe the procedures, findings and
outcome of a surgical operation.
 Anesthesia notes:
These provide information regarding the type of anesthesia given, and
related details.
 Progress notes:
These records include new information and changes during patient
treatment. These are written by all members in the care team, and the
information included comprises observations of the patient’s physical and
mental condition, changes in the patient’s condition, vital signs at certain
intervals, bladder and bowel functions, food intake and so on.
 Radiology reports:
These notes are related to the findings of imaging studies such as X-rays,
MRI, scans and so on.
 Discharge summary:
A hospital discharge summary is prepared when a patient checks out of
the hospital. It gives the reasons for the hospital admission, results of the
tests made, and how the patient feels after the discharge. Any medical
advice provided may also be included.
Reference:
Types of Records Retrieved by Medical Record Retrieval Services By
MOS Medical Reviews | Published on Apr 14, 2023 | Medical Record
Review)
 Introduction to Electronic Health Records (HER):
Electronic Health Record, commonly known as HER include a digital
representation of a patient’s medical record. It includes diagnoses and
treatment plans, prescriptions or allergies, as well as testing outcomes.

Contrary to paper-based records, EHRs are real-time safe, and easily

accessible data to authorized users. It facilitates smooth communication
and coordination between medical professionals through smart health
kiosks.

Types of Electronic Health Record Systems

Patient Demographics:
The core of any HER is the patient’s details, such as names, addresses,
contact details, insurance as well as emergency contact numbers. The
data ensures accuracy in the recognition and monitoring of patients
throughout healthcare settings.

Medical History:
EHRs contain comprehensive medical histories which include past
medical conditions such as surgeries, vaccinations as well as allergies and
your family’s medical history.
The information provided by EHRs provides healthcare professionals
with essential information regarding the health of a patient and helps to
create the patient’s treatment plan.

Laboratory Results:
Integration of laboratory systems allows EHRs to record and display tests
for diagnostic results like urine analysis, blood tests as well as imaging
studies.

Healthcare providers can quickly access the outcome to monitor patients’

progress, make educated decisions, and modify treatment plans as
needed.

Medication Lists:
EHRs keep up-to-date lists of medications that include prescribed
medication doses, frequency as well and refill information.

This can prevent the occurrence of medication errors, interactions and

unwanted reactions with a thorough summary of the patient’s present and
previous medication.

Treatment Plans:EHRs assist in the design and administration of

treatment plans such as prescribed medicines, treatments, procedures as
well as subsequent appointments. Healthcare providers can collaborate
with these plans to ensure the continuity of treatment and adherence.
Comparison of EHR as well as EMR
EHR vs EMR
Electronic Health Records (EHR) and Electronic Medical Records
(EMR) are frequently used interchangeably but there are distinct
contrasts.

Both systems digitalize the health records of patients, EHRs go beyond

the boundaries of healthcare institutions. It brings an extensive
understanding of a patient’s medical background through several
healthcare providers and settings.

Electronic health record vs electronic medical record

Benefits of Electronic Health Records:
1- Improved Patient Care
EHRs aid in coordinated health care by providing healthcare
professionals immediate access to pertinent information about the patient,
which allows for prompt diagnosis, timely treatment intervention and
preventive health strategies.

Patients gain from improved messaging, less wait time and improved
safety by providing warnings about allergies, drug interactions and
indications for treatment.

2- Enhanced Efficiency
Moving from paper-based records to electronic records will eliminate
manual procedures like file filing, retrieval and transcription.

3- Better Data Management

EHRs allow the gathering of storage and analysis of massive quantities of
data from patients and data, opening the way to healthcare management
for the population as well as clinical research and improvements in
quality.

Data analytics tools can identify patterns, trends, and outliers. They allow
healthcare institutions to make informed decisions based on data to boost
results.

Implementation of Electronic Health Records Systems:

Incorporating the EHR system is a process that requires meticulous
planning, stakeholder engagement and strategies for managing change to
warrant an easy transition process and maximize the gains.
Healthcare providers must consider the technical aspects, including the
compatibility of systems, data migration as well as comparison and
cybersecurity in addition to addressing culture and workflow concerns.

Examples of Electronic Health Records Systems

Records Systems
Many Electronic Health Records systems are extensively used in health
care settings with distinct features and functions that are specifically
designed to meet the requirements of different practices and specialties
situations. Examples include:

Epic Systems Corporation

The company is known for its extensive EHR solutions utilized by big
hospitals and medical academic centres. It offers features like integrated
workflows for clinical care and decision-support tools and portals for
patient engagement.

Cerner Corporation
EHR solutions to boost efficiency in clinical and operational processes
across a range of healthcare environments. It offers modules to benefit
from electronic health records managing the revenue cycle as well as
population health management and much more.

Allscripts Healthcare Solutions

Provides a variety of EHR products that cater to the demands of small to
medium-sized practices, as and large-scale healthcare institutions. Offers
custom EHR solutions that include features including e-prescribing and
clinical decision support, as well as interoperability features.

Medical Technology
Offers integrated EHR solutions to be used in smart care hospitals
ambulatory settings and various other healthcare institutions. It is
renowned for its user-friendly interface, interoperability functions and
assistance to make clinical decisions.
Electronic health records (EHRs) are electronic versions of a patient’s
medical history that can help improve patient care and reduce medical
errors. Here are some examples of HER systems in Pakistan:
Shifa International Hospital
A pioneer in introducing EHRs in Pakistan, Shifa aims to be a paperless
tertiary care hospital.

PKLI–HPTC
This system maintains a complete electronic medical record for each
patient, as well as inventory records of medicines.
Indus Hospital
This hospital has implemented an EMR system that securely stores and
accesses patient health records electronically.

Aga Khan University and Hospitals

This institution uses an HER system called AKU OneHealth to provide
doctors with evidence-based clinical decision support.

Fouji foundation Hospital Rawalpindi

This hospital has implemented an EMR system that securely stores and
accesses patient health records electronically.

Advantages and Disadvantages of electronic health records

Advantages
● Information Sharing Streamlined:

Allows quick and easy access to the patient’s records for licensed
healthcare professionals.

It facilitates smooth communication and coordination between the

various health professionals who are involved in the care of patients.

● Increased Safety for Patients:

Lowers the chance of making mistakes caused by handwriting that is not

clear or paper documents that are lost.

Healthcare providers are informed of potential allergic reactions or

interactions with drugs to increase the security of medication.

● Improved Productivity and Efficiency:

Automates mundane tasks, such as appointments and refills which saves

time for health professionals and patients.
Facilitates faster recording and the retrieval of information about patients
This payoff in faster and faster workflows in the clinical setting.

● Data-driven Decision-Making:

Gives you access to all of the patient’s details, including medical histories
as well as results of tests, results as well as treatment plans. This allows
medical professionals to make more informed choices.

Facilitates evidence-based practice and research by providing large

databases to study.

● Better Payment and Reimbursement Procedures:

It streamlines documentation and coding to reduce billing errors while

ensuring accurate reimbursement.

Allows for timely filing of claims. Also, it allows electronic billing to

speed up billing and payment cycle control.

Disadvantages
● Costs of Implementation and Limitations on Resources:

The cost of initial set-up associated with electronic health records (EHR)
Systems can be significant. This includes hardware, software, as well as
the cost of training.

Maintenance and upgrade projects on a regular basis could be expensive,

particularly for smaller health centres.

● Security and Privacy Concerns:

Electronic health records are vulnerable to security breaches, data leaks

and improper access, which raises concerns about the security of patient
information.

Compliance with privacy laws like HIPAA (Health Insurance Portability

and Accountability Act) is vital, but it can be challenging to ensure.

● Disruptions to Workflows and Opposition to Change:

Moving from paper-based systems to electronic methods can interrupt
workflows, and will require some time to adjustments.

Certain healthcare professionals may be resistant to EHRs because of

concerns regarding changes to work procedures or perceived diminished
autonomy.

● Interoperability Issues:

EHR systems of different manufacturers could not communicate

seamlessly with each other, leading to problems with interoperability.

Insufficiently standardized formats for data and protocols could hinder

the transfer of information about patients across different healthcare
institutions.

● The Burden of Documentation on Healthcare Providers:

Role of (EHR) Electronic Health Record in Pakistan

Aspect Country Response Year Introduced Percentage/Status
National HER System Yes 2013
Legislation Governing National EHR System Yes
Health Facilities with EHR
– Primary Care Facilities Yes 25-50% utilization
– Secondary Care Facilities Yes 25-50% utilization
– Tertiary Care Facilities Yes 25-50% utilization
Other Electronic Systems
– Laboratory Information Systems Yes 35% utilization
– Pathology Information Systems No 18% not
implemented
– Pharmacy Information Systems Yes 33% utilization
– PACS No 26% not implemented
– Automatic Vaccination Alerting System No 10% not
implemented
ICT-assisted Functions
– Electronic Medical Billing Systems Yes 58%
utilization
– Supply Chain Management Information Systems No
58% not implemented
 – Human Resources for Health Information Systems Yes
69% utilization
The statistics provided are sourced from the World Health Organization
(WHO) for Pakistan’s healthcare infrastructure. These metrics reflect the
WHO’s assessment of electronic health record (EHR) systems and related
electronic infrastructure within the country.

Pakistan is rapidly advancing in AI telemedicine, with Fitwell Hub

emerging as the largest telehealth ecosystem startup in the country,
offering a comprehensive platform for healthcare delivery. It offers a
cloud-based Electronic Health Record (EHR) system alongside
telemedicine services, enabling healthcare providers to offer remote
consultations and manage patient records efficiently. Fitwell Hub aims to
revolutionize healthcare accessibility and delivery in Pakistan by
leveraging technology to connect patients with healthcare professionals
seamlessly.

(Tayyaba Saleem,Role Of Artificial Intelligence In Healthcare And

Medicine)

The Legal Implications of Inaccurate Documentation

Legal requirements for medical record completeness:

Medical record completeness is often legally mandated. Laws and regulations
require healthcare providers to maintain comprehensive records. Incomplete
records may lead to non-compliance with these laws, putting the provider at risk of
legal penalties and disciplinary actions.

Medical malpractice claims:

Incomplete medical records are a significant factor in medical malpractice claims.
When a patient’s health suffers due to incomplete documentation, it can be grounds
for a lawsuit. Properly maintained records serve as crucial evidence in defending
against malpractice allegations.

Patient confidentiality and privacy violations:

Incomplete records may inadvertently expose patients’ private information or
violate their confidentiality. Breaches of patient privacy can result in legal actions
and fines, damaging a healthcare provider’s reputation and finances.

Legal consequences for healthcare providers:

Healthcare providers who maintain incomplete medical records can face various
legal consequences. These may include fines, sanctions, license revocation, or even
criminal charges in cases of severe negligence or privacy breaches. Additionally,
institutions may incur legal liabilities for failing to ensure record completeness
among their staff.

Inaccurate documentation in Pakistan’s healthcare system can lead to serious legal

implications. Here are some key areas affected, along with references to relevant
laws and guidelines:

1.Medical Malpractice
Inaccurate patient records can lead to claims of negligence if a healthcare provider
fails to provide the standard of care. Under the ‘Pakistan Penal Code’(PPC),
negligence can result in civil liability.

- Reference: Pakistan Penal Code, Sections related to negligence and

tort liability.

2. Informed Consent
Proper documentation of informed consent is crucial. Inadequate or inaccurate
consent forms can expose practitioners to liability if complications occur, as
patients might claim they were not fully informed.

- Reference: The ‘Medical and Dental Council Ordinance, 1962’,

emphasizes the importance of informed consent.

3.Regulatory Compliance
Healthcare providers must comply with guidelines from the ‘Pakistan Medical and
Dental Council (PMDC)’ and the ‘Health Care Commission’. Inaccurate
documentation can lead to penalties, loss of licenses, or sanctions.

- Reference: ‘PMDC Regulations’ and the ‘Health Care Commission

Act, 2010’.
4.Patient Safety and Quality of Care
Errors in documentation can lead to serious patient safety issues, including
medication errors. This could result in lawsuits for damages caused by negligent
care.

- Reference: The ‘Pakistan Medical Association’ provides guidelines

on maintaining patient safety and quality of care.

5.Insurance Claims
Healthcare providers must document treatments accurately to ensure insurance
claims are processed. Inaccurate records can result in claim denials and financial
repercussions.

- Reference: ‘Insurance Ordinance, 2000’ governs the conduct of

health insurance practices.

6.Legal Records and Evidence

Medical records serve as crucial evidence in legal cases. Inaccuracies can
compromise the integrity of these records, affecting case outcomes.

- Reference: ‘The Evidence Act, 1872’, outlines the admissibility of

documents in legal proceedings.

7.Health Information Privacy

The protection of patient information is governed by laws regarding data privacy.
Inaccurate documentation that leads to breaches can result in legal actions.

- Reference: ‘The Electronic Transactions Ordinance, 2002’,

addresses issues of data privacy and security.

8.Criminal Liability
Deliberate falsification of medical records can lead to criminal charges under the
PPC.

- Reference: Relevant sections of the ‘Pakistan Penal Code’

concerning forgery and fraud.