- Home
- » e-Newsletters
Tip: Define these terms in EHR documentation policy
EHR Connection, October 13, 2008
An EHR documentation policy establishes the expectation that every clinician will use the EHR to access and retrieve information, enter data, and respond to clinical decision support interventions at the point of care.
Definitions of pertinent terms are an essential component of any policy. Be sure to include these definitions in your EHR documentation policy:
- Point of care refers to the use of the EHR in proximity to the patient, such as to support positive patient identification, obtain accurate and complete information for documentation, and appropriately communicate clinical findings to the patient
- Real time refers to use of the EHR at the time data are captured and used
- Clinical decision support interventions (rules) are the specific alerts, reminders, recommendations, and other interventions that the clinical decision support system generates
This tip is from The No-Hassle Guide to EHR Policies published by HCPro, Inc.
Most Popular
- Articles
-
- HIPAA Q&A: Flu shot requirement for hospital employees
- Running an effective peer review committee meeting
- HealthDataInsights posts new issues for medical necessity claims
- Sneak Peek: Effort underway to establish caseload benchmarks
- Q/A: Coding for telescopic intraocular lens
- New FAQ posted on storing laryngoscope blades
- Tip: Perform your own internal investigation prior to government audit
- HIPAA 5010 deadline extended, but threat remains, says AMA
- HHS task force: Consider privacy, security with text messages
- What does case-mix index mean to you?
- E-mailed
-
- Running an effective peer review committee meeting
- HIPAA Q&A: Flu shot requirement for hospital employees
- HHS task force: Consider privacy, security with text messages
- What does case-mix index mean to you?
- Q/A: Coding for telescopic intraocular lens
- Q/A: Correct use of modifier -PT
- Tip: Correctly code bilateral pain management procedures
- "Wall fountains" may be spreading Legionnaires to patients, visitors
- 2012 CPT code changes for ASCs: Shoulder and knee scopes and pain management
- COT basics to best
- Searched