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Waiting for EMR? Here’s some way to make paper records fly

Ambulatory Safety Monitor, December 2, 2004

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Although technology can improve efficiency and productivity, it comes at a price that many ambulatory surgery centers (ASC) can't afford. One of these luxuries is electronic medical records (EMR), which have helped many organizations put an end to loose papers and towers of folders. For other facilities that can't afford the expense, however, EMR are not an option.

Both the JCAHO and the AAAHC require organizations to document and maintain accurate medical records for each patient they serve (JCAHO standard IM.6.10 and AAAHC standard 6.A), but they are silent on how to achieve this. Therefore, if your facility still walks the paper trail due to financial constraints or because the switch to EMR is too massive an undertaking, that's okay. Check out how one facility in El Paso, TX, made paper work for them.

Formulate an efficient system

When Gina Marie Briones, performance improvement coordinator at Centro San Vicente, an ambulatory community health center, went through a JCAHO survey this year, the surveyor suggested the facility maintain more thorough medical records. In response to this, Briones developed forms that serve as checklists, with fewer blanks that require writing. For example, the new history and physical (H&P) form contains mostly questions that the healthcare provider checks off. The H&P notes specific labs for the physician to check off the appropriate one and avoid written orders. "This way, there's no question what was ordered," Briones says.

Centro San Vicente also simplified its progress notes form by using a checklist design with only a few areas that require writing. If you use a checklist, keep it short. Too many pieces of paper can intimidate providers, Briones says, and lead them to believe the task is too time-consuming.

*Tip: If you create similar forms for efficiency's sake, make sure your staff are aware of the liability hazards associated with incomplete paperwork. Blanks on preprinted forms make an organization vulnerable when trying to defend malpractice claims.

Gauge your staff's approval

If your staff finds a new approach useful and time efficient, expand it to other areas. Centro San Vicente currently is looking into preprinted prescription pads. Although her facility uses a smaller formulary, facilities with larger formularies could benefit from preprinted prescription pads for common drugs, such as ibuprofen, Briones says.

She received positive feedback on her new forms, which users report result in less work, JCAHO surveyor satisfaction, and a more accurate process because staff clearly understand orders. Before using the checklists, Briones says, notes were often illegible and written all over the page.

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