Page 13 - Part 2 Navigating Electronic Media in a Healthcare Setting

SVMIC Navigating Electronic Media in a Healthcare Setting

using dropdown boxes in order to avoid selecting an incorrect
medication or dosage. The source of the authorization for the

medication order should always be documented. If an alert or

alarm is triggered because of contraindications or potential drug
interactions with other medications, this alert should be noted in

the record as well as how it was addressed or why it was
overridden. If it is triggered because of a dosing problem (e.g. high

dose, wrong route), the dosage and name of the drug should be
rechecked to verify correct medication was selected from the

dropdown menu. Again, if correct, note this alert in the record, how

it was addressed and why it was overridden. If an alert or alarm is
triggered because of a notification that the quantity of medication

prescribed or the duration of the medication prescribed exceeds

that of the recommended limit, recheck the quantity and duration
ordered to verify these were selected accurately from the

dropdown menu. If there is a good medical justification to exceed
the recommended dose or duration, the provider should document

such.

Native Form VS. Printed Copy

A hardcopy printout of the EHR can sometimes differ significantly

from the image that is on the monitor screen being viewed by the
provider (native format). This can create problems and cause a

record to be suspect when a patient or his/her attorney requests a

hard copy printout of the medical record. Practitioners and staff
should be familiar with what information is and is not printable

from the EHR. If a patient, representative or attorney requests

copies of the EHR, the hard copy should be reviewed to insure it is
complete and any discrepancies noted prior to forwarding the

information to the patient, representative or attorney.

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