Page 23 - Risk Reduction Series - Documentation Essentials (Part Two)
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SVMIC Risk Reduction Series: Documentation Essentials
☐ Work with the EHR vendor to minimize the number of
necessary clicks to get to the relevant information.
☐ Do not accept the template that is initially selected for
the encounter until the pertinent data is evaluated and a
template that is appropriate is verified.
COPY & PASTE
☐ Use copy and paste with extreme care.
☐ Never copy from single patient record to another record.
☐ Never paste information that has not been read and edited
as necessary for accuracy.
☐ Never copy information in a manner to make it appear that
services were provided that weren’t personally provided.
☐ Do not copy information if it is not pertinent to the current
encounter.
☐ Do not copy or insert lists into a progress note unless it
has been validated.
☐ Use only approved abbreviations in notes, and verify the
appropriate template is being used.
☐ If copy and paste is appropriate, avoid using undated
phrases such as “last week” .
AUTO-POPULATION
☐ Know what findings are auto-populated with each
template.
☐ Have auto-populated data “tagged” or an alert created.
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