8/24/2013

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EMR-Friend or Foe?

Documentation: 50% of your Job

Preserving the Workflow

FAQs

Avoiding Booby Traps and Charting Deficiencies

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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!