emr-friend or foe
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8/24/2013
1
EMR-Friend or Foe?
Documentation: 50% of your Job
Preserving the Workflow
FAQs
Avoiding Booby Traps and Charting Deficiencies
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8/24/2013
2
Household Items
Orthotics casting Biomechanical measurements
Use Biomechanical form and scan into chart
Shoe size Weight Plaster trap in workroom sink for plaster water
Clean your instruments Autoclave periodically, and after all AIDS/Hepatitis C
patients
Get to know where forms and supplies are in the clinic
Exploding the Record
Cloning
Macro/Keyboard shortcut use
OIG-identical documentation as fraud 32 regulatory agencies feasting at the audit banquet
EMR=LAZY
Increasing Documentation requirements Nails
Shoes
Critical issues lacking PROS, description of pathology and rationale of treatment
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Getting Started: Workflow 1 Patient Management
Check-in Record room number on checklist at front desk Vitals-
Manual BP if BP high-bring your cuff!!! Add extra vitals line and record BP and pulse, then add additional information (eg.
manual, repeat) using the Medcin view
VITALS: if BP significantly high, especially with neurological/cardiovascular symptoms, alert attending/residents immediately at the beginning of the visit so that patient can be sent to ER if necessary
Record smoking history
New Patient Shoes off, patient in chair, basic chief complaint(s), Get attending. Inform resident if attending not available Write New Patient on a post it note and place by Dr.s computer if attending
is not yet available to meet the new patient
Surgical minded patients Cast changes/x-rays-heads up to residents/attendings prior to working up the
patient
Getting Started: Workflow 2 The Note
Starting note-To avoid note/billing disconnect Check in chart for any existing note for that date Add Documentation Tool
Do not import all history or the entire note Automatic deficiency for erroneous documentation Banned buttons: Select All and Import All. Under NO circumstances should
these buttons ever be pressed!
Use appropriate form New patient, Established patient, Nail debridement Diabetic shoe fitting, Diabetic shoe dispensing Careful about switching forms, unclicking boxes
Any box with text-if the box is clicked again on the form, your text will disappear
PMH-PCP and if applicable: vascular/cardiologist/nephrologist Meds should match a PMH diagnosis Before presenting, input the vitals and use the Meds Module to input
meds and allergies
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Using the Medications Module-Part 1 (mortar and pestle icon)-Do in this order!
1st window of meds module:
Check for pharmacy input
If empty, notify front desk to rectify during visit BEFORE patient leaves
If no meds/allergies, click those boxes in lower right hand corner-MUST be done BEFORE marking Allergies reviewed/Meds reconciled button !!
Click X to close the window, second window will open
2nd window: Meds tab
Click Current meds button: Add new medications (routed meds option, use search feature), click Apply, then close the window without saving to avoid repeats
Note: If a medication is not found, add using the path: Est. patient form/Plan/Prescribed Meds box-type in medication. Can also add the additional information patient will bring in list or pharmacy contacted for list in this box
Discontinue any meds: Click on the medicine to highlight, then click Discontinue
Click Meds Reconciled box
2nd window: Allergies tab( if no Allergies tab, document Allergy status in HPI box)
Note: May be imported automatically with Documentation Tool
Add Allergies button to record an allergy
To add additional information for an allergy, click on the allergy to highlight, then click the Details icon found on that line.
Mark Allergies Reviewed box
Using the Medications Module-Part 2 (mortar and pestle icon)-Do in this order!
Click the Refresh button (on ribbon of Navigation or Medcin tab) Then go to Import/Other (in the Medcin ribbon)- and go to the
meds and allergies tabs Click these to add any meds or allergies not yet imported into your
document (always refresh first!!!)
Last step: If discontinued meds show up on current notes meds list, you should now delete them in Medcin view by highlighting the blue text and pressing the X button.
Important: If patient has no meds or allergies, Recheck the Medcin view of the note to see if it shows this in the note. If it does not, you must add the statements no known drug allergies to the HPI section and No known medications using the : Est. patient form/Plan/Prescribed Meds box
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The Medical Reporter: Fact-finding mission
Finding information Chart notes
Previous plan (s) Tab sections of patient charts:
Misc Index- labs, prescriptions, imaging/vascular reports, etc Procedures Radiology tests
Patient Correspondence-in Medcin module PT Rx Referral notes Imaging Rx Diabetic Shoe Rx
Special Sections of your clinical note-Categorize!!
Radiographs Click box in Clinical examination in the forms mode only if x-rays taken that
day Pedal Radiographs taken Record relevant findings-do not record findings that are not present!
Objective after musculoskeletal exam for placement of MRI/review of outside med records/labs MRI can go in radiographs box if x-rays were taken that day
Social History Smoking status of all patients each visit
Record from Vitals tab, add additional information in Medcin mode If there are repeats in medcin mode, improper importing is the cause
Occupation line-complete, do not leave open ended sentence Sitting/desk job and help at home, especially for elderly patients (assisted living vs
independent community ambulators)
OARRS-put in social history section under No Drug use OARRS report reviewed and scanned Record relevant findings
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IMPORTANT HPI is for NLDOCAT and PCP information. Do not Space Fill your HPI
with information better categorized elsewhere in the note. You can present the pertinent PMH/PROS to your attending as part of an
integrated HPI, but do not document it this way in the medical record. ROS-Do not record No N/V/F/C/CP/SOB/pedal complaints in the HPI. Click
those boxes in the ROS sections of the forms mode Booby trap alert: Record +/- leg swelling as pertinent in the HPI due to a bug in the
program. Exception-if working with Dr. Rachel Johnson, ask her specifically which ROS items
should be in her notes in the HPI section for that individual patient. (eg. The N/V/F/C items for a wound patient)
PMH-use the forms mode to record Meds/Allergies-See Medications Module instructions for details
Do not add in or delete any items to the Assessment portion of the note Any blue links already added by the attending in medcin view can be clicked
on and additional informational text added using the square icon The Attending will specifically direct you if they want you to add a blue linked
item to the assessment Please let the attending of record know if you accidently change the
Assessment portion, or else your attendings note will not match their billing submission in an audit, subjecting them to fraud charges.
FINISHING UP
Record in all notes before leaving for the day: Basic Plan (but then flesh out more of the details later) Basic CC/HPI
Read over note in the Medcin module for readability and accuracy before flagging. Clean up all repeated/conflicting documentation. Booby Trap Alert: If smoking status is repeated/conflicting, you can get a deficiency for
improper importing (erroneous documentation), since it will then be impossible to delete these links due to the way the program is set up. Acceptable: Never a smoker:Never a smoker Unacceptable: Former smoker: Former smoker, Never smoker: Never smoker, Current smoker
Recheck your hard copy paper notes to make sure that all information was transferred correctly to the computer chart. (ex vitals, plan)
Can make changes after flagging, but before clinician sign-off
Not documented, not done! Not done, dont document that you did!
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