If you are giving the patient a medication, it should be related to a problem that is on the patient’s problem list (implied in this is the principle that you should know what all the medications are for). Putting info in your note implies that you have reviewed it and acted accordingly. It is not enough to have a medication list or labs pull into your note. The notes serve as a way to organize your thinking and demonstrate that you have reviewed relevant information and acted on it. You are responsible for EVERYTHING that is in your notes. Unless there are elements that you know are required, you should delete any sections of the templates that are not relevant for the patient at that time.
Note templates are designed to make documentation easier and more accurate. If you want the more detailed template, import phrase “.UMHNEUROEXAMTEMPLATE” You should start each note with a blank exam and then fill in those elements that you performed. For the daily progress note templates, the Neuro exam section has been pared way down to just major categories ( delete those that you have not examined that day and include only what you did). The exam documented in the notes should EXACTLY match the exam that you actually performed on the patient that day. The more irrelevant detail you add, the harder it is to find the relevant information.ĭO NOT COPY FORWARD – You should start each note with a blank page, then can bring in the basic note template and fill in the details new each day.ĭO NOT use “NORMAL EXAM” TEMPLATES. DO NOT pull in extraneous info and avoid ‘Note Bloat’. Include only information that is relevant for patient care. If this is done, it should be clearly stated where/when/who that information is coming from. This will lead to legal problems as it will raise suspicion that the note may have been copied from another note in the chart that cannot be easily identified, or that it may have been copied from another patient’s chart, which is absolutely forbidden.Ĭopy/Pasting in sections from other authors without appropriate attribution: It may be appropriate at times to include some elements of other’s notes. If you write a note in word or other outside program and then copy into EPIC, it will appear as “copied from outside chart”.
Pasting things into medical record from outside chart: In EPIC, you can see where copy/paste elements originate. It also leads to the “note bloat” phenomenon which makes it difficult to find relevant information that is needed for patient care.Įach note should be started with a blank page and a new blank template and then ONLY a few key elements should be copied in from other places in the chart. did you in fact check all the same elements on exam and the patient responded in exactly the same way, or did you just copy exam forward).
This makes it unclear what has been performed that day (i.e. Some things that many people are doing that ARE NOT ALLOWED:Ĭopying forward major elements of notes from prior documentation: However, this has fostered the idea that “more it better”, leading to the note bloat phenomenon in which notes frequently contain redundant, contradictory, superfluous, and/or out of date information. The EMR is designed to optimize billing by making it easy to include many elements in documentation. Legal – notes must be accurate and with sufficient detailīilling – Documentation must be sufficient to support billing. Patient care – notes must be timely, and succinctly and accurately convey the current status and plan for the patient
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