MRI Principles of Health Care Documentation
Key principles that should be adhered to health care information systems (and their
accompanying policies) are established:
x Unique patient identification must be assured within and across healthcare
documentation systems.
x Healthcare documentation must be
Accurate and consistent.
Complete.
Timely.
Interoperable across type of documentation systems.
Accessible at any time and at any place where patient care is needed.
Auditable.
x Confidential and secure authentication and accountability must be provided [MRI,
2004, p.3].