Page 24 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

☐ Abnormal and normal findings may be built into a template.

☐ Uncheck and check boxes to provide additional
information when needed.

☐ Read the note in its entirety to verify accuracy.

☐ Do not sign the note until it has been reviewed.

☐ Print office notes periodically to ensure your
documentation accurately reflects the care provided.

INCONSISTENT PROCESSES

☐ Select a single medical record documentation system.

☐ Conduct user training on EHR.

☐ Eliminate workarounds and variation in processes.

☐ Work with EHR vendor to accommodate requests for
modifications.

☐ Insist on consistency in documentation standards among
providers and staff.

☐ Ensure everyone has knowledge and mastery of the office
systems and that both clinicians and management have
input into the systems chosen with a focus on efficient and

thorough documentation.

☐ Include all potential users in training on new technologies
and documentation policies.

☐ Develop action plans to address EHR transitions.

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