Page 10 - Part 2 Navigating Electronic Media in a Healthcare Setting

SVMIC Navigating Electronic Media in a Healthcare Setting

CASE STUDY

A 53-year-old presented to the ER on January 9, 2015. The patient
subsequently requested her records and now disputes

numerous entries, including ones noting that she has Type II

diabetes, suffered a TIA and is menopausal. The physician used
preset notes and now acknowledges the documentation errors

she and the nursing staff made. The patient filed a complaint with

the hospital and State Medical Board.

Patients and juries alike want to see individual care. The best way
to evidence individual care is by using the patient’s own words

wherever possible in the documentation. If a patient describes her

pain as feeling as if someone stuck an icepick in her, document
that in the narrative portion of the EHR in quotation marks as

patient described pain as “feeling as if someone stuck an icepick in
her”.

Inconsistent Processes and Workarounds

The adoption of a new EHR system almost always requires

changes in office and hospital processes and workflows. Couple
this with the fact that not all physicians and staff are comfortable

with the use of the EHR system (or that they are required to use
different EHR systems at different locations - hospital vs. office, for

example), and it may lead to the creation of workarounds to

accomplish the same level of productivity that was achieved prior
to the adoption of the EHR system. Unfortunately, these

workarounds may not reflect the complete picture and lead to

inconsistent processes which can be very confusing and
frustrating. When staff members cover for other staff, the varying

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