Question

A hospital allows the use of the copy functionality in its EHR system for documentation purposes. The hospital has established explicit policies that define when the copy function may be used. Which of the following would be the best approach for conducting a retrospective analysis to determine if hospital copy policies are being followed?


A. Survey practitioners to determine if they are following hospital policy
B. Observe the documentation practices of all clinical personnel
C. Institute an in-service program for all hospital peronnel
D. Randomly audit EHR documentation for patients readmitted within 30 days

Answer 1

Answer: Randomly audit EHR documentation for patients readmitted within 30 days.

Explanation: To determine if hospital policies are being followed, a random judicial examination of electronic health records (EHR) is the best. This is because the probability of getting an accurate result is high since it's just a random sample.