Legal Documentation in the Electronic Medical Record

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Legal Documentation in the Electronic Medical Record:

Legal Documentation in the Electronic Medical Record Miriah Boocher, RN, MS, APRN, BC, FNP, ONC Free image courtesy of FreeDigitalPhotos.net

Data Collection:

Data Collection Healthcare Providers collect data and create care plans for their patients Data are stored in paper medical records or electronic medical records Transitioning from paper to e lectronic will forever change the way health care is documented.

Purposes of the Medical Record:

Purposes of the Medical Record The medical record has multiple purposes: Repository for patient management documents Collection of business data Legal document as evidence of the gold standard of care in a legal proceeding

The Vision of Electronic Medical Records:

The Vision of Electronic Medical Records Improve the quality of patient care by: Improving provider access to data Improve documentation Provider prompts Decision support and guidelines Access to education materials

Electronic Medical Record and Provider Documentation:

Electronic Medical Record and Provider Documentation Time efficiency is an important facilitator or barrier to electronic medical record implementation Electronic medical record increases the completeness of provider documentation Non-essential information slowed down providers

Clinical Decision Support Tools:

Clinical Decision Support Tools Tools are used to: Make gains in performance Narrow gaps of knowledge Improve safety of patient care Assist providers in making healthcare decisions

Complete and Accurate Documentation:

Complete and Accurate Documentation Never document an acute abnormality found during the physical exam without documenting the corresponding intervention Never document an intervention without documenting the evaluation Never document a body system abnormality without elaboration Document the patient’s baseline mental status, if known Never be complacent with check-off assessments

Electronic Medical Record and Significant Changes to Documentation:

Electronic Medical Record and Significant Changes to Documentation Advantages Disadvantages Legible documentation Decreased documentation time Improve communication between providers Quick information retrieval Link different patient information sources Standardized terminology Discomfort with technology Extensive training Expense of initial implementation

Documentation as Evidence:

Documentation as Evidence Document the encounter at or near the time of the exam Patient encounter documentation during the normal course of business

Documentation as Evidence:

Documentation as Evidence The importance of authorship Standard and efficient equipment Identification of the authors Alterations must be noted Quality checks

Conclusion:

Conclusion This concludes our presentation for today Take Our Quiz!! Go to https://sites.google.com/site/electroniccharting/ Free image courtesy of FreeDigitalPhotos.net

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