Provided by: Jennifer Kirschenbaum, Esq.
March 12, 2019
Can you give some reasons as to why it is NOT a good idea to copy/paste emails regarding a patient, into that patient's EHR? A lot of emails tend to have anecdotes and smiley faces that just don't seem appropriate for a medical record- even though some of the substance of the e email may be pertinent- such as the dr giving a directive. Is there a way to convey to staff some solid reasons to not copy/paste emails, but rather paraphrase in a telephone note instead?
Thanks in advance, M
For one, OPMC and OPD are keen to award punishments to practitioners with unprofessional or cavelier notes. One of my first experiences in healthcare law was learning the ramifications of a certain resident's license who penned "little old lady fell out of bed, another inch to the left and she'd be dead" into a note. Not pretty.
Secondly, patient medical records are for forever, as far as your staff are concerned. Conveying this message to staff "solidly" should include conveying that to remain employed, they are to follow the guidelines established for patient medical record creation and maintenance. If emails are to be transcribed or documented in the "telephone note" format, explicit policy procedures should be implemented and enforced for all staff members across the board, evenly.
Today, documentation is critical. Be ready to fire over staff insubordination. Be sure to properly document any trainings, directives, expectations AND misconduct - evenly across all staff members. Remember, when it comes to enforcing promulgated practice policies, we do not play favorites....
Zoc Doc update?
Anyone have updates for the group on updated pricing conversations??