Page 23 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

Tips to Avoid EHR Pitfalls

 TEMPLATES

 Create a brief narrative note which provides additional

details about the patient.

 Documenting even one or two sentences of a provider’s
overall impression and treatment plan can go a long way to

help understand the presentation and plan.

 Evaluate templates to see if they promote over-

documentation.

 Work with the EHR vendor to modify standard templates to
reduce the potential for inaccurate notes.

 Train staff on the appropriate selection of the template.

 If the root cause of an adverse outcome is determined to be

“failure to select the appropriate template”, the breadth of

training that was conducted will be scrutinized.

 Customize the desktop to easily see all pertinent information
and then change the template based on observations.

 A provider may need to talk with his or her EHR vendor to

help minimize the number of necessary clicks to get to the

needed information.

 Do not accept the template that is initially selected for the
encounter until the pertinent data is evaluated and a

template that is appropriate is verified.

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