EMR question

dog

I am new to the world of EMR...and am seeing its good points and its bad points. Have a question for the experienced:

Very often I see the physicians copy and paste into their notes data from elsewhere, including radiology reports. If they paste a CXR or CT report into their note without commenting on it, do you consider that part of their note or just a background finding? I.e., do you then accept the findings of the CXR without further investigation?

Thx,

Renee


Linda Renée Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

fosterma

Renee, Here at OHSU in Portland Oregon, it was decided in the Epic planning stages that if a provider brought in labs, radiology reads, CT's, MRI's, ECHO reports when signed off by the attending we would consider them agreed and documented by a "hands-on" provider/clinician. It is always helpful if they include the info in the assessment and plan as that indicates clinical significance. Your Epic team with HIM guidance would be the deciding group for your policy. Hope this helps.

Roberta Fosterman RN
Clinical Documentation Specialist
Mail Code OP17A
Phone 503-418-4024
Fax 503-494-8439
fosterma@ohsu.edu

robert.hodges2

Renee,

I accept it because they brought it into their note, but I do like a comment too. We also monitor copy and paste closely because of VA rules regarding that. There are a log of potential pitfalls with copy and paste. Not the least of which is copying information from one patient to another patients record. It is a process that we discourage.

Robert

Robert S. Hodges, BSN, MSN, RN
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
 
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens