The Abstractor

Volume 2, Issue 3: 9/29/15

Bi-Weeekly Focus: Copy & Paste - makes things easier...NOT ALWAYS!

As you follow the patient throughout their visit, documentation of the critical elements in the EMR is super important. Often times, we use copy & paste to make our documentation easier or faster. However, sometimes we really need to read what was already written and only add the new information because things have changed.


I have witnessed some not-so-good copy & pasting a few times. I have read where a patient has had treatment and is now ambulating with a device. However, the copied information states otherwise. Who is correct? What should I document on the data collection forms?


I have seen where one person documents that a patient is left handed. However, another person recorded they were right handed. What should I record?


This does not happen often, but when it does, it can be confusing and causes more time for me to figure out which information I should use.


So bottom line: be careful when copying & pasting existing exam notes, or progress notes, and ensure the information you are copying & pasting is accurate across the board.


Our databases are only as good as our documentation within the EMR.

Words to think about!

REMEMBER:

One of my goals is to make sure that the documentation we collect on patients is more uniform and filled with details that paint a clear picture of the patient's visit. Having clean data allows us to make informed decisions regarding patient outcomes. Patient outcomes demonstrate if the treatment used, worked or needs to be revised. Thank you for doing your part with collecting the right data.

~~~~~ Is this true? Maybe al little? ~~~~~

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A BIG THANK YOU TO.....Dr. Welch

You have been the most consistent with documenting if a patient is left, right or both handed. Thank you for making the details matter.