Page 35 - APP Collaboration - Assessing the Risk (Part Two)

SVMIC Advanced Practice Provider Collaboration: Assessing the Risk

• Do the notes accurately reflect what you did and

observed?

• Take the time to uncheck the boxes in your template.

Review for inconsistencies before signing.

• Avoid non-standard abbreviations.

• Remind staff that tasking is a permanent part of the

record. Personal texts and emails are often informal and
it’s easy to let the habits of informality slip over into the

medical record tasking, which could give the impression
of unprofessionalism or lack of caring about the severity of

the patient’s situation.

Any electronic health record system can fail. Whether or not
the failure is with a component of the EHR or with the internal
user policy, it is the user’s responsibility to vet and correct the

issue. Workarounds are sometimes created by system users

in order to fix perceived problems in the EHR and to increase
efficiency. However, do-it-yourself workarounds are strongly
discouraged as they may very well lead to the failure of EHR

support functions and ultimately result in patient harm. Although

they initially can be expensive, customized EHR features from
the vendor may prevent patient harm and accordingly be the
most cost-effective resolution in the long run. Taking the time to

learn and have a mastery over your EHR system should increase

efficiency and help you document the best possible note to tell
the complete, accurate story of patient care.

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