Page 20 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

Avoiding the pitfalls that can result from auto-population

requires first that a provider knows what a template
automatically includes. If at all possible, have the data that was

auto-populated tagged or the provider alerted to the specific
fields which were completed in this way. Depending on the

template that is selected, it is possible 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.

Dropdown boxes in computerized prescription order entry

(CPOE) can also pose a preventable error. E-prescribing
can result in serious errors if the prescription is not carefully

reviewed before being sent. While you may have a staff member
enter the information, you assume all responsibility for accuracy

once you sign the prescription. A well-designed EHR will list
medication choices on the dropdown menu according to the

strength of the drug in ascending order (lowest dose as first
choice). This prevents selecting the strongest dosage in error.

If your system lists medication doses in descending order
(strongest dose at the top of the dropdown menu), consider

making a system adjustment.

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-

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