Unit 6: EHRs and Communication Flashcards
Etiquette
Make appropriate eye contact with patients while interviewing and engage them about the information provided
Never badmouth another healthcare provider or the patient’s family in the healthcare record because you never know who will look at it.
The EHR document is what is used in malpractice cases
Narratives (progress notes), orders, and assessments
forms of communication between care providers abut the patient
The Joint Commission looks at medical records as proof of communication among staff
Patient education
If you don’t document it, accreditation agencies won’t count it
Documentation and professionalism
Consider your audience Be professional Don't use slang or text speech Proper spelling and grammar Approved abbreviations
CDI: Clinical Documentation Improvement specialists
Review charts for appropriate documentation
Functions of the medical record
Record complaints, conditions, or problems
Providers examination or intervention
Provider’s assessment
Treatment plan decision making process
Patient responses to treatment
Meeting organization and licensure requirements
Reimbursement (payment of a claim)
Minimizing malpractice claims
Medical record uses
Primary source of patient information
Assess the provider’s critical thinking
Determine the credibility of the provider
Evaluate treatment decision making
Determine appropriateness of care provided
Minimize malpractice risk
Reimburse properly (like medicare payments)
What questions documentation should address
Who What Where When Why How
Pros of email
Fast Easy Avoid telephone tag Rapid communication Allows for reminders Saves money/ Reduces Staff time
Cons of email
No control over forwarding of emails Legal issues Misaddressed emails can result in HIPAA issues Risk of miscommunication Too lengthy messages
Email legal issues
Confidentiality
Content may be missed or over looked
How to store the email for record keeping
Message length
Too lengthy messages may result in a provider not reading the entire email and miss pertinent information
Miscommunication
Someone may misinterpret the tone of an email
SOAP Format
Subjective
Objective
Assessment
Plan
Subjective
Patient’s description of the problem
