Page 21 - Part Two Risk Reduction Series - Documentation
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SVMIC Risk Reduction Series: Documentation
that pre-populated findings include normal as well as abnormal
findings already built into the template. Take the time to review
which boxes have been checked and unchecked to make sure it
accurately reflects the visit. Before signing the note, be sure to
review the entries documented by staff. If their selection is
inconsistent with the provider’s, this discrepancy creates questions
about the credibility of the entire visit.
Finally, it is also important to print the office note periodically to
see what is in the printed version of the record. In some EHR
systems, what appears to be present in the office note when
reviewed from the computer screen may not be the same
information that is included when the medical record is printed. If
the EHR system automatically populates parts of the office visit
note from a medication list, allergy list or medical history, it is
important that a provider knows that these data sources will also
need to be reviewed for accuracy.
Pitfall #4 – Inconsistent Processes Among Users
The adoption of an Electronic Health Record system in the practice
almost always requires changes in office processes and workflows.
Coupled with the fact that not all physicians and staff are
comfortable with use of the EHR, this may lead to the creation of
workarounds to accomplish the same level of productivity that was
achieved prior to the adoption of the new system. Unfortunately,
these workarounds then lead to inconsistent processes and a lack
of standardization with documentation.
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