Improving Clinical Documentation Integrity

Abstract

Health information technology (health IT) has been widely adopted by physician offices and hospitals as a result of federal legislation. Health IT has reduced some types of documentation errors and introduced others. Like errors in other industries, health IT documentation errors can be considered execution errors or planning errors that occur within a context of latent conditions. This chapter describes some latent conditions that contribute to these errors and specific tactics are suggested to mitigate the patient safety risk from them. The chapter concludes with a proposal to share physician documentation with patients and caregivers as a method to reduce multiple health IT documentation errors simultaneously.