According to the Centers for Disease Control and Prevention (CDC), every day, 91 Americans die from an opioid overdose. Many health IT leaders believe that health information management, including proper documentation and interoperability of electronic health records (EHRs), can play a vital role in addressing the opioid epidemic.
The American Health Information Management Association (AHIMA) released an opioid addition documentation tip sheet to help healthcare providers better document the use and abuse of opioids.
When an individual using or abusing opioids visits a physician or other healthcare provider, that medical professional is responsible for accurately recording information about the patient’s opioid use in their EHR. However, without nationally adopted communications standards for health information exchange, that documentation is often not shared across healthcare systems and state lines, allowing those with opioid addictions to seek the drugs from multiple physicians without their knowledge, AHIMA officials said.
“There are seven characteristics of high quality clinical documentation. If a provider learns how to document using these characteristics to guide their documentation habits, they will provide trustworthy documentation,” AHIMA officials stated.
According to the tip sheet, those characteristics that best define optimal EHR charting are: clear, consistent, complete, reliable, precise, legible and timely. AHIMA's tip sheet lays out characteristics of clear EHR charting alongside hypothetical examples of what clinical documentation for potential opioid abusers would look like if they were followed.
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