8/24/2013

EMR-Friend or Foe?

Documentation: 50% of your Job

Preserving the Workflow
FAQs
Avoiding Booby Traps and Charting Deficiencies

8/24/2013

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

8/24/2013

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

8/24/2013

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

8/24/2013

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 noteCategorize!!

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

8/24/2013

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!