Page 24 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

 COPY & PASTE

 Use copy and paste with extreme care.

 Never copy from single patient record to another record.

 Never paste information that has not been read and edited

as necessary for accuracy.

 Never copy information in a manner to make it appear that
services were provided that weren’t personally provided.

 Do not copy information if it is not pertinent to the current

encounter.

 Do not copy or insert lists into a progress note unless it has

been validated.

 Use only approved abbreviations in notes, and verify the
appropriate template is being used.

 If copy/paste is appropriate, avoid using undated phrases

such as “last week”.

 AUTO-POPULATION

 Know what findings are auto-populated with each template.

 Have auto-populated data “tagged” or an alert created.

 Abnormal and normal findings may be built into a template.

 Uncheck and check boxes to provide additional information

when needed.

 Read the note in its entirety to verify accuracy.

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