Page 3 - Part Two Risk Reduction Series - Documentation

TABLE OF CONTENTS

PART TWO ................................................................................................... 5

Documenting Communications with Patients ........................... 5

Informed Consent ..................................................................................... 6

Discharge Instructions and Educational Materials ................. 13

What Should Not be Documented/Maintained in the
Medical Record ........................................................................................ 13

Unique to Paper Charts ....................................................................... 14

Documentation – Pitfalls in Electronic Health Records ..... 14
Pitfall #1 – The Use of “Cookie Cutter Templates” .................. 16

Pitfall #2 – The Use of “Copy & Paste” ......................................... 18

Pitfall #3 – Auto-Population .............................................................. 19

Pitfall #4 – Inconsistent Processes Among Users .................. 21

Tips to Avoid EHR Pitfalls.................................................................. 23

Documentation via Scribe ................................................................. 25

Thorough Documentation .................................................................. 26

Documenting After an Adverse Outcome ................................ 31

Avoid Using Disclaimers for Dictation, Voice Recognition
Software or EMRs ................................................................................... 32

Conclusion ................................................................................................... 36