Clinical documentation integrity: Its role in health data integrity, patient safety and quality outcomes and its impact on clinical coding and health information management

Abstract

Clinical documentation has been defined as "information that is recorded about a person's care. The primary purpose of clinical documentation is to facilitate, safe, high quality and continuous care. . .and is stored within a health record" (Australian Commission on Safety and Quality in Healthcare, 2023). It needs to accurately reflect clinical events and decision-making for purposes of care continuity and communication. However, the quality and utility of clinical documentation has influence well beyond its primary purpose of supporting patient care. The World Health Organization has defined data integrity as:The degree to which data are complete, consistent, accurate, trustworthy, and reliable and that these characteristics of the data are maintained throughout the data life cycle. The data should be collected and maintained in a secure manner, such that they are attributable, legible, contemporaneously recorded, original or a true copy and accurate. Assuring data integrity requires appropriate quality and risk management systems, including adherence to sound scientific principles and good documentation practices (World Health Organization, 2016; cited in Victorian Agency for Health Information, 2018).