Documentation
Only facts not feelings
What is objective documentation
The purpose of EMR documentation
What is....... Continuity of care, Billing and Medical Malpractice
Criticism of care provided or perceived mistakes made by other practitioners
What is AVOID this type of documenation
This is not proper documentation
The EMR does what?
What is our source of continuity of care
Makes providers documentation easier, but you have to review prior to saving
What is Templates/Copy forward function
They make life easier, but at times we forget to uncheck an item from a previous visit.
Treated a pt that fell. How do you capture it
What is document the event in the EMR
Nurse screening note
What is document the provider assessment on the nurse screening note
The pt has not filled her medication for the past 6 months due to the cost and verbalized not understanding why she needed it.
What is Identified barriers vs frustration!
It is easy to become frustrated with "non-compliant" pt's. Reflect with the pt's assistance to understand why.