Policy or written guidelines for handlilng cloed or cut/paste notes
I am working with physicians in our organizaton to develop guidelines regarding the use of the cut & paste function in generation of a note or other official document in the electronic medical record. Does anyone have anything they would be willing to share? If not, can you refer me to anyone who might be able to provide input or provide an example or draft? We have the AHIMA papers regarding this issue but no thers references. Thanks in advance!!
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Lisa
Lisa Romanello,RN,BSN,FNS,CCDS
Manager, Clinical Documentation Improvement Specialist
CJW Medical Center
Quality and Compliance
804-228-6527
Sharon Cole, RN, CCDS
CDI Specialist
254.751.4256
Sharon.cole@phn-waco.org