Electronic record

lfleurylfleury
in CDI Talk Archive
Our facility is in the process of switching from hand written progress notes to electronic progress notes. Currently our (clinical documentation nurses) clarifications go into the written progress notes; soon we will no longer have paper charts. Does anyone work at a facility that is all electronic? How do you communicate your clarifications to the physicians?

Lauren Fleury

Lauren Fleury RN, BS, CCDS
Clinical Documentation Nurse Team Leader
Quality Management
Berkshire Medical Center

Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    All electronic here. I actually met with our providers and asked them how they wanted to get their clarification requests. Most want to be paged with encrypted email as a backup. We do require all responses be documented in the health record.

    So far so good J

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov


    “Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge
  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    Most have some sort of electronic communication built into the system --
    -- an email type function
    -- sticky notes
    -- formal coding query process
    -- deficiency management
    etc.

    What system are you using? Would likely get responses from folks using the same system.

    We use EPIC, and use both the inbasket for concurrent queries and the coding query process for queries after discharge & coding.

    Don
  • lsipos@monument.healthlsipos@monument.health
    edited May 2016
    Lauren

    ...LOL a work in progress...currently we are still a hybrid system so still leave the paper query in the chart and a note in the doctors box to let them know which pt's have queries...

    However, supposedly our MEDITECH upgrade in 5.65 is going to have a function that will allow "electronic queries" to attach to a particular patient or physician....time will tell. Work with your Clinical Informatics folks and maybe they can shed some light! Good luck...if you figure out a process, let us all know!


    Juli Bovard RN CCDS
    Clinical Effectiveness/Clinical Quality
    Rapid City Regional Hospital
    719-4390 (work)
    786-2677 (cell)
    "No Limit to Better......"


    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
  • ssalinasssalinas
    edited May 2016
    Juli -

    If Meditech's 5.65 does allow the electronic query, please share.

    Thanks,
    Sharon Salinas, CCS
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    ssalinas@barlow2000.org
  • lsipos@monument.healthlsipos@monument.health
    edited May 2016
    ABSOLUTELY!!! :)



    Juli Bovard RN CCDS
    Clinical Effectiveness/Clinical Quality
    Rapid City Regional Hospital
    719-4390 (work)
    786-2677 (cell)
    "No Limit to Better......"


    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    We are all electronic using Cerner. We have an electronic process to attach queries to the patients chart and forward them to the MD for response/signature. They receive the queries in their "message center" which they have to check all the time to verify labs and such so they definitely know they are there. Though they do not always respond....

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • lfleurylfleury
    edited May 2016
    Our EMR system is Meditech and I'm not sure what version and I think the
    doctors are piloting Patient Keeper for their notes.

    Lauren
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