Quick Tips from the Past

Over the last couple of days, I've had a chance to spend time with a number of the hospital medicine docs. This is a terrific group of highly motivated CIS users who, on the whole, know how to use the system as efficiently and effectively as any. But I learned a couple of things from them today. First, I should never assume that old tricks lose their meaning. And second, much of what we know now about PowerNote documentation will hold true when we go to Enhanced View.

In response to a couple of great questions that I've answered in the past, but in another context, I've attached two slide sets: one a single compact slide on the use of Copy to New Note, a useful but potentially hazardous means of doing serial documentation; the other reviews how to select and default the Document Type, aka folder location.

I must remind you that, in order for a note to be considered clinically meaningful and legally legitimate, it must be updated and revised with integrity. The copy function is best used when passing off a note, e.g. Physician Discharge Summary, that is started by one physician and adopted by another. This allows for authorship to be assumed by the doc who has done the copying. On the other hand, when a progress note is copied one day to the next, you MUST make sure that the overnight events, vital signs, labs, and impression and plan are relevant and current. I can assure you that an auditor will catch on and this can bring serious consequences. I won't dwell on this, since I'd rather be advising you on how to make documentation easier.

I hope these are helpful. I've got more where these came from, so if you've got some basic questions about documentation or chart navigation, just ask.


Uploaded on authorSTREAM by nrk99

Uploaded on authorSTREAM by nrk99