Clinical documentation and health data quality in the adoption of electronic medical records: A review of varied scoping strategies

Abstract

Background/Objectives: Health data quality is the degree to which healthcare datasets meet data quality standards such as accuracy, accessibility (and so on), and are acceptable based on users’ level of confidence at any health facility. Good quality health data enhances communication among all care givers and in effect, improves the quality of care rendered to the teeming patients, whereas, poor quality documentation may mean poor quality clinical care and repressively affect the patients. Design/Methods: A scoping review of literature relating to health data quality, clinical documentation processes and electronic medical record adoption was carried out. Search terms used were health data, data quality in health, health data quality, clinical documentation, health records, electronic medical records and electronic health records. Search engines deployed include Google Scholar, Pubmed/Medline and ResearchGate. Results: Electronic medical record has been said to have significantly improved the overall quality of the clinical notes and the quality of all its elements, including the core and non-core elements. The availability of electronic health data and new data collection tools provides both challenges and opportunities for deepening and expanding quality measurement and for improving health data quality. Conclusion: The implementation of EMR is considered a means for improving health data quality and quality of healthcare services to the teeming patients. In spite of challenges slowing down the pace of EMR adoption, maintaining better documentation and health data quality in EMR is far better and much easier than in paper-based health records system. There is need to improve the way healthcare systems are measured, the way healthcare data are collected and utilized and that collection of data not needed should be stopped. Keywords: Clinical documentation; Electronic medical records; Health data quality; Health outcome; Patient’s safety