By now, most of us have moved beyond the initial phases of implementing an EMR and into the optimization phase. Templates, ordersets, and documentation tools are constantly evolving with input from different departments and clinicians but we need to ensure a centralized EMR change review process is in place to prevent duplication, errors, note bloat, conflicting information, and unnecessary documentation.
Since there are many different uses and objectives for clinical documentation, we must collaborate with many different areas to reach a consensus on the way we capture clinical documentation to ensure compliance. In my experience, the best way to standardize EMR changes and enhancements is to develop a centralized process flow for all requests for changes to clinical documentation. This establishes the team that will provide diverse perspectives and will review and sign-off on all requests before they are built and implemented.
Sometimes we get approached by physicians or other clinicians asking for changes that would be a simple build in the EMR but we must run this and all requests through the change approval process to prevent any potential downstream affects. Even when requests are based on regulatory changes, it’s important to follow the process flow so that all interested parties are aware of the changes and are meeting compliance in all areas.
From the coding and CDI perspective, we need to capture more detail in the documentation to properly assign ICD-10 codes. Adjusting EMR templates to help physicians with descriptive diagnoses is vital to capture all of the detail at the point of entry and time of treatment instead of asking for clarification later. At my facility, we have found success with having our CDI specialists educating the physicians on the diagnosis guidelines and appropriate EMR template use.
The number one objective should be to ensure the EMR captures the clinical story of each patient to provide the best possible treatment and utilization of resources. Achieving consensus on templates can sometimes feel like herding cats but doing it right the first time is important. We must maintain a governance process of clinical documentation to ensure all objectives are properly met.
If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.
