Page 21 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

visit note from a medication list, allergy list, or medical history, it
is important that a provider knows that these data sources will
also need to be reviewed for accuracy.

PITFALL #4: INCONSISTENT PROCESSES AMONG USERS

The adoption of an electronic health record system in the
practice almost always requires changes in office processes

and workflows. Coupled with the fact that not all physicians
and staff are comfortable with use of the EHR, this may lead

to the creation of workarounds to accomplish the same level
of productivity that was achieved prior to the adoption of the

new system. Unfortunately, these workarounds then lead to
inconsistent processes and a lack of standardization with

documentation.

Some practices continue to rely on a paper record even after

the adoption of an EHR. The use of paper and EHR records for
a patient makes it impossible to identify a single source of truth

for the patient’s health information. Information in one or both
records can be incomplete or inaccurate which creates risk for

the provider as well as other providers covering for him or her.
It should also be noted that, increased likelihood of medical

error can occur during the conversion from a paper system to
an electronic system, or during upgrades within the electronic

system.

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