Page 16 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

Utilization of an EHR can promote patient safety, improve

accessibility of information and enhance continuity of care.

However, the adoption of any new technology can have
unintended consequences. One of the unintended consequences

of EHR technology is less than optimal documentation. Although

legibility issues are virtually eliminated, other unique

documentation pitfalls have arisen due to electronic health

records.

The following are common issues presenting unique challenges

when documenting in an EHR: templates, auto-population, copy

and paste and inconsistent processes.

Pitfall #1 – The Use of “Cookie Cutter

Templates”

In some systems, a template may be created based on checking a

list of systems. As the visit progresses, it may become apparent
that the template chosen may not be the correct one. As a

physician or practitioner, necessary documentation should be

made to ensure the visit note accurately reflects both the care

provided and thought processes. Although it can be helpful to

have a template to use as a starting point for documentation of a
patient office visit, it can easily lead to over-documentation.

Hurriedly clicking check boxes or failing to de-select boxes can

inadvertently result in a 2 to 3-page office note which includes

elements which were not assessed or provided. This over-

documentation can increase liability exposure if it does not
accurately reflect what took place.

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