Page 25 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

 Do not sign the note until it has been reviewed.

 Print office notes periodically to ensure your documentation

accurately reflects the care provided.

 INCONSISTENT PROCESSES

 Select a single medical record documentation system.

 Conduct user training on EHR.

 Eliminate workarounds and variation in processes.

 Work with EHR vendor to accommodate requests for
modifications.

 Insist on consistency in documentation standards among

providers and staff.

 Ensure everyone has knowledge and mastery of the office

systems and that both clinicians and management have

input into the systems chosen with a focus on efficient and
thorough documentation.

 Include all potential users in training on new technologies

and documentation policies.

 Develop action plans to address EHR transitions.

Documentation via Scribe

With an increasing documentation burden, some practices have

begun using scribes as a cost-effective and efficient way to help

providers spend more time focused on patients. A scribe is an
extension of the provider, and it takes time and effort to train

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