Page 22 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

Avoiding the pitfalls of inconsistent processes can only be

accomplished with office-wide focus on the creation of
standard processes for use with the EHR. Eliminate duplicating

medical record documentation in multiple systems. Select
one system and convert all medical records to the system

chosen, and conduct training to ensure staff and providers are
knowledgeable and proficient.

Tips to Avoid EHR Pitfalls

TEMPLATES

☐ Create a brief narrative note which provides additional
details about the patient.

☐ Documenting even one or two sentences of a provider’s
overall impression and treatment plan can go a long way to

help understand the presentation and plan.

☐ Evaluate templates to see if they promote over-
documentation.

☐ Work with the EHR vendor to modify standard templates to
reduce the potential for inaccurate notes.

☐ Train staff on the appropriate selection of the template. If
the root cause of an adverse outcome is determined to be

“failure to select the appropriate template”, the breadth of
training that was conducted will be scrutinized.

☐ Customize the desktop to easily see all pertinent
information, and then change the template based on

observations.

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