Question

Taking short-cuts in any profession can be a risk, but when it comes to health record documentation, short-cuts can impact the patient, provider, and health care entity. You are the clinical operations manager of the new surgical center.

You manage all physicians and other ancillary providers. You discover that no formal policy exists regarding “best practices” for EMR documentation.

Create a 2-3 page policy on EMR Best Practices

• Include an introductory paragraph explaining the purpose of the policy.
• Divide the policy contents into two sections: administrative staff, and clinical staff.
• Include at least three best practices (some of these may be the same for both administrative and clinical staff, but you should strive to identify specific best practices for each group).
• Include at least four (two for admin, two for clinical staff) common mistakes, short-cuts, etc. and how and why to avoid them.
• Your policy should use formal and professional verbiage.
• On a separate page, list a minimum of three references in APA format.

Answer 1

POLICIES FOR BEST PRACTICES IN EMR DOCUMENTATION

purpose of policy

• to improve quality of care provided by improving all aspects of patient care
• Improved patient outcome and safety through better management and documentation.
• Reduce medical errors
• Avoid unnecessary investigation.
• Improved communication and interaction among primary care providers, patient's.

​​​​​BEST PRACTICES FOR ADMINISTRATIVE STAFF

• Identify computer skills of employees and provide them basic training.
• Train them only specific areas they are going to practice.
• Designate one or two super users( most skilled)

BEST PRACTICES FOR CLINICAL STAFF

• Take advantage from online resources provided by EHR vendor
• Conduct post implementation feedback sessions.
• Train nursing staff and doctors.

COMMON MISTAKES BY ADMINISTRATIVE STAFF

• Patient misidentification- patient id error
• Billing errors

COMMON MISFAKES BY CLINICAL STAFF

• Prescription errors
• Mixing up Patient information

METHODS TO PREVENT ERROR

• Pay attention while documenting relevant documents., because wrong information will lead to soo much complications
• Enter correct codes in computer - wrong codes will lead to billing errors.
• Aviod prescription errors by paying attention while writing.