Promoting Quality & Safety in Oncology Electronic Health Records
How much documentation is required and what is the best way to do it?
Is it better to type or dictate and transcribe
Is it acceptable to copy and paste templates
Is it acceptable to copy and paste templates
Replies to This Discussion
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Permalink Reply by Kathleen Finster on -
Since you are a part of the Varian group, I assume you are using Aria.
We have found that the way a person documents depends on their time, comfort with the system, and typing skills.
Our physicians mostly dictate, we have a couple who use dragon and do their own notes without transcription.
For those who dictate, they usually dictate only the CC, HPI, Imp, Plan. The rest is pulled into their templates with tags from the software.
Consult templates are more dictation than pull in for some doctors, Follow-up templates are more pull in than dictation.
We don't use a lot of copy and paste. Aria does have a "get last" feature to pull in previous information.
k
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Permalink Reply by Jamil Khatri on -
Thanks Kathleen, that was helpful. The big question is "How much language should be in the EMR". The EMR serves two basic needs. One is documentation for the health care providers which can be abbreviated using short direct sentences. The other is for Medicare and other payers. This is where things become a little murky. For example is it enough to say "The risks and benefits of adjuvant chemotherapy were discussed in detail and all questions were answered" or does one have to put in as much "Language" as possible and does that really prove anything.
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