Documentation: Our Journey to the EHR (so far!). Laura Triplett, Director, HIM Roseann Kilby, Clinical Informatics Analyst Becky Crane, Clinical Risk Manager. 367 Bed Community Health System in Quincy, Illinois 2,000 Employees 240+ Physicians Affiliates include:
Laura Triplett, Director, HIM
Roseann Kilby, Clinical Informatics Analyst
Becky Crane, Clinical Risk Manager
- Illini Community Hospital (Critical Access Hospital in Pittsfield)
- Community Outreach Clinic
- Denman Medical Equipment
- Denman Biomedical
- Quincy Health Care Management
- Blessing Physician Services
Schools of Nursing, Radiology and Laboratory
Legal Medical Record Policy – Maintains the timing of implementations
Example: documentation of pulse oximetry requires the observation for documentation for patient requirements of oxygen
"This document was copied forward from H&P, dated XXXX, visit XXXX. Please see additional update for this visit, XXXX, by Dr. XXXX, the attending of record."
What you document in the system may not look the same when printed
Summary Statement : Alert/oriented. Wearing bi-pap at night and ET CO2 monitor. At times respirations were down to 9, held dilaudid until in teens. States is having urinary hesitency and feeling as if he is not empying bladder. Did bladder scan which showed no residual. Wife in room all night with him. C/O pain 5/10 to bilateral arms and back @ worst, 2/10 following dilaudid. No other complications.
Item from pick list must be selected in order for header to be visible on printed report.
In the first column, the nurse manually typed in “L” and “FiO2”. In the second column, the nurse did not. When printed out, only the numbers appear – see next slide
A plaintiff’s attorney has 2 years* to thoroughly
review the chart for errors and omissions.