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Electronic Medical Records Best Practices

Electronic Medical Records Best Practices

The use of electronic medical record systems have become the standard in hospitals and medical practices around the country. The times of those file folders packed with pages of patient information and indecipherable notes are long gone.

Many don’t realize it, but EMR systems play a large role in patient satisfaction, preventing physician burnout, and keeping staff happy.

Let’s face it, without these systems we would be lost. With the proper training and some common sense your EMR system can be the key to the success of your organization. Let’s take a closer look at just some of the electronic medical records best practices:

Proper Training is The Key

Top notch training at the start of implementing a new EMR system or for a new hire provider, will reduce errors in diagnosing, treatment, and care plan.

The lack of proper training on the use of the system can lead to aggravation of the users, which can progress to defeat. You may think that taking the time for training is a waste of money and time. But in the long run it will lead to happy and satisfied clinicians.

It is important to remind providers throughout the use of the system to be mindful of the “alerts” that pop-up. And, they should remember to check for test results if they have been ordered.

Proper training allows clinicians the opportunity for comprehensive patient notes, usage of the correct diagnosis, and clean claims for reimbursement.

One Chart at a Time

It is extremely important not to record patient information in the wrong chart. This can be avoided by only having one chart opened at a time. Some electronic medical record systems will not let you have more than one chart opened at a time, only in some situations.

Best practice is to get in the habit of working in one chart. Remember, once a chart is “signed” it is difficult to make corrections, whether through an addendum or a strike out, the info is there forever.

Be Consistent

Naming files or folders in your system should be consistent and everyone should be informed as to where to file a report or paperwork. For example, all radiology reports can be filed in the “radiology” folder. If you are an orthopedic practice, you may want to separate your x-rays, CT’s, or MRI’s, by making a folder for each. Patient paperwork such as Demographics, Insurance Cards, Driver License, HIPAA form, Consents, might be filed in a “Demographics” file or they may be separated, respectively.

Whatever process that you decide or which folder to use for what, should be communicated to each clinician and staff member. This will provide for consistency and less frustration and more time saving for all.

Utilize Templates

Consult with your providers to create templates and specific terminology that they would like to use to make patient records clear and concise. Your EMR vendor or IT department can generate their selections.

Referring back to training, make sure that these templates or any specific terminology is communicated to all providers. And, remember to share with your future hires.

Stay Secure

Each provider and staff must have their own unique login. Sharing of login information such as username and password is not allowed.

Verify with your IT department that your computers are set to lock/log off after being left unattended for a specific period of time (choose seconds/minutes rather than hours).

Make sure that each computer is out of your patients view.

Laptops should not be left unattended especially in patient exam rooms. Provisions should be made for security of laptops when not in use or left for long periods of time to deter theft.

Desktops and laptops should be numbered and a list secured.

Daily Backups

Whatever system you are using should be “backed up” at least once per day. This can be set up by members of your IT department, who can decide when and what type of back up to be used and how it will be stored. You can decide to do partial backups daily and entire system backup every few days or once per week. This is crucial in case of power outages, system failures, etc.

Software Updates

Check if updates are periodically provided and if you can request changes or additions to the system from the vendor.

Security Software

Once again, your IT department should be consulted as to the type of anti-virus and anti-malware software you are running on your system. Don’t for get to ask about the Firewall, too.

You can ask them to notify you if there is an unauthorized attempt to access your system and to let you know how it was handled. If such a breech, occurs there should be upgrades or improvements to your anti-virus and anti-malware as needed.

Use the Right System

A majority of electronic medical record systems are designed for primary care or specialties. Selecting the right system could save time, money, and frustration down the road for everyone including your IT department.