Improving Perioperative Data Integrity and Quality via Electronic Medical Record Reconciliation

Abstract

This case study investigates data integrity and quality within the perioperative process via embedded quality control check (QCC) rules, used within a business process management framework to support patient care documentation, performance reporting, patient billing, data analysis, and regulatory agency audits. The study identifies specific perioperative nursing care documentation as electronic medical records and demonstrates how QCC rules, an embedded QCC process, and QCC rule violation reconciliation is applicable to ensuring data integrity and quality within integrated hospital information systems. Based on a 166-month longitudinal study of a large 1,157 registered-bed academic medical center, this study provides a priori business process management examples of data integrity and quality within the perioperative process. Recognizing existing limitations, potential capabilities, and the subsequent contextual understanding are contributing factors that yield measured improvement. Theoretical and practical implications and/or limitations of this study’s results are also discussed.