Utilizing the EHR (Electronic Health Record) offers the providers, greater access to patient information, improved patient care, care coordination, and potential for cost savings. There are also challenges this documentation tool can bring to the provider in terms of documentation. Templates can be beneficial but should offer flexibility to the provider for ease in updates or the benefit of free text if allowable.
- Ensure documentation is patient specific and age appropriate. The EHR at times may set the provider up for clicking inaccurate information. For example, a patient who is bed-ridden should not have documentation that states gait normal.
- What goes in may or may not be what comes out. Ensure you or someone is reviewing your pdf, tiff, and paper printed documents to ensure your intent is there. A depression screen should print negative and positive components of the screen and documentation should support treatment for drug therapies administered.
- Understanding the patient is important to other caregivers as well as other entities reviewing the record. Documentation should reflect the current state of the patient as well as alternatives, risks and benefits of evaluations and treatments. This goes as far as including a review of likely outcomes if a treatment is withheld or refused. If the patient leaves AMA state potential patient risk. The 5Ws for Documentation and Auditing offers good tips.
- Be careful with copy and paste functionality. This can certainly save time but can bring forth inaccurate information that may require updating. Editing information pasted over potentially could not be updated or edited as appropriate. An example is, Ms. Notme who has had the same vital signs and normal physical findings every day; all day of her 2 day visit. Small things similar to this can turn into compliance and risk issues as well as hinder coding and billing processes and impact audit defense.
- Develop some policies and guidance around utilization of the problem list. Many facilities and areas within facilities utilize this list differently. Ensure you are all on the same page with is uses and limitations. Keep in mind that something that seems irrelevant to you may be beneficial to another provider. Instituting a quality review process around this area could be beneficial.
Physicians can struggle with translating the art of treating the patient into fluid documentation to justify coding and fully reflect what is happening with the patient. Having the visual on the patient certainly lends a different view if the visual can be documented appropriately; such as the patient is septic looking or further describing the COPD (chronic obstructive pulmonary disease) patient carries their oxygen usually because they are O2 dependent and describing the COPD as acute on chronic if presenting symptomatology describes this.
Sharon Easterling, MHA, RHIA, CCS, CDIP, FAHIMA