A health care organization cannot have high-quality health care information without
first establishing that it has high-quality health care data.
Medical Records Institute (MRI) identified 5 major functions that are negatively
affected by poor-quality documentation (MRI, 2004).
1. Patient safety is affected by inadequate information, illegible entries,
misinterpretations, and insufficient interoperability.
2. Public safety, a major component of public health, is diminished by the inability
to collect information in a coordinated, timely manner at ye provider level in
response to epidemics and the threat of terrorism.
3. Continuity of patient care is the adversely affected by the lack of shareable
information among patient care providers.
4. Health care economics are adversely affected, with information capture and
report generation costs currently estimated to be well over USD 50 billion
annually.
5. Clinical research and outcomes analysis is adversely affected by a lack of
uniform information capture that is needed to facilitate the derivation of data
from routine patient care documentation.
Healthcare documentation having two parts: information captures and report
generation. Both have to be considered in order to have high-quality documentation.
Information captures is the process of recording representations of human thought,
perception, or action in documenting patient care, as well as device-generated
information that is gathered and/or computed about a patient as a part of health care.
(MRI, 2004, p. 2)
Report generation consists of the formatting and/or structuring of captured
information. It is the process of analyzing, organizing, and presenting recorded
patient information for authentication and inclusion in the patient healthcare record.
(MRI, 2004, p. 2)