Download Electronic Medical Record Etiquette For Alec ELECTRONIC

Electronic Medical Record
Etiquette
For Alec
ELECTRONIC MEDICAL RECORD DOCUMENTATION
RESPONSIBILITY & USE POLICY
A. INTRODUCTION
1. The Electronic Medical Record (EMR) at the Anne Arundel Health System(AAHS) is shared by
providers and staff across ambulatory and acute care settings in multiple specialties, clinics
and departments. In order to realize the quality benefits of Alec, and maximize provider
utilization of the shared record, it is essential that all providers observe a common set of practice
principles when using the EMR.
2. The guidelines set forth herein define principles of use and serve to foster a common
platform among all medical staff on how the EMR will be used. The intent is to provide
a framework and guidance to the medical staff. It is expected that all members of the medical staff
will demonstrate a high level of professionalism and professional courtesy by making every
reasonable effort to be compliant with the guidelines.
B. GENERAL PRINCIPLES
1. Ownership of information contained within medical records belongs not to the
providers, but to the patients. Maintenance of these shared records is the responsibility of all
providers contributing to each chart. Primary responsibility for chart maintenance falls to the
primary care physician and co‐managing hospital-based primary providers when needed by the
patient. However, all providers are responsible for contributing to chart maintenance as it relates
to the care of their patient.
2. Access to a comprehensive medical record is predicated upon the record being complete.
Documentation should be completed in a timely manner following patient encounters and
completed without delay when the patient is or can be expected to have additional encounters
within the immediate future (for example, urgent referral to specialist, ED,
admission, acute illness).
3. Ensure that information in the record is correct. If ancillary office or departmental staff add
or edit entries in the record (Problem List, PMH, PSH, Medication, Allergies, SH, FH), providers
are responsible for confirming the accuracy of this work.
4. Have respect for the entries of other providers; it is only appropriate to change the entries
of other providers when those entries are in need of an update (e.g. refining the diagnosis), are
outdated, in error or are not consistent with guidelines.
C. PROBLEM LIST
1. The Problem List is a physician managed list of an individual’s medical problems in the
medical record. This list is accessible in all care contexts. In addition to contributing to
continuity of care, it triggers various clinical decision support tools such as Best Practice Alerts
and problem focused order sets. Leveraging this valuable tool requires that it be accurate, current
and populated in a consistent manner by all clinicians.
2. All providers (PCP, specialists, and covering physicians) caring for a patient have a
responsibility to update and manage the Problem List, especially for those problems
pertinent to their specialty.
3. New problems should be added to the list by the clinician making or refining the
diagnosis, or by the clinician reviewing outside documentation.
4. Desirable items to include on the list:
Appropriate Content for Problem List Examples
 Chronic medical problems requiring continued treatment, screening or monitoring
Type 2 Diabetes, Essential hypertension, Renal insufficiency, Developmental delay

Recurring acute medical problems requiring evaluation or treatment
Recurrent UTIs, Recurrent shoulder dislocation

Problem requiring the prescribing of scheduled or PRN medications chronically
Anxiety, Migraine, Sciatica; SBE prophylaxis candidate

Problems requiring laboratory testing for monitoring
Thyroid disease, Anticoagulant long‐term use

Acute symptom while under active evaluation for diagnosis
Abdominal pain, Low Back Pain, Changing skin
Lesion

Active or relapsing chemical dependency or abuse
Tobacco abuse, Narcotic Dependence

Family history of disease that conveys a significant health risk upon the patient
Family history of BRCA gene positive, Family history of Huntington’s Disease

Chronic mental health disease
Depression, Bipolar disorder

Positive screening tests that impact continuing care or disease risk
Abnormal PAP, PSA or PPD
5. Items to exclude from the list:
Inappropriate Content for Problem List Examples
 Inactive or historical medical problems and completed surgeries
Meningitis, Appendectomy

Minor, self‐limited illnesses or complaints
URI, Rash

Non‐problems
Physical exam, Vaccination, Counseling

Family history of limited or no significant health risk to the patient
Family history of appendectomy

Screening study diagnosis
Screening mammogram

Symptoms, when a diagnosis exists
Cough when Asthma is present
Chest Pain when Acute MI is diagnosed

General diagnosis, when a specific one exists
Sciatica when Herniated lumbar disc is present
6. Maintenance of the Problem List (for both Inpatient and Ambulatory visits):
• Should be performed at each clinical encounter (outpatient visit, admission, consult,
rounding, discharge, etc.).
• Inactive problems should be removed using the “resolved” button within the Problem
List Activity (for example, once the hypokalemia is corrected, take it off the Problem List).
• The delete button should only be used to remove erroneous entries.
• Surgical problems should be resolved from the Problem List following the surgical
correction of the problem and post operative care is complete.
• Procedures and results should be listed in the Past Surgical History (PSH), not with the
corresponding medical problem in the Problem List (e.g., colonic polyps may be on the
Problem List, but the last colonoscopy should be in PSH and/or in the Overview section
of the Problem list – see #9 below).
6. Hospital specific issues:
• Be sure to identify the “Principal Problem.” This may change during the course of the
patient’s stay.
• Mark all the problems being addressed during the hospitalization as “Hospital Problems”
• Perform Problem Maintenance as described in the above section.
• At the time of discharge, reconcile all problems. Clean up the Problem List to ensure its
accuracy for the patient’s ongoing care, whether that is at their Primary Care Provider’s
office, or in the hospital.
• The Final Diagnosis should be marked as “Principal Problem.”
8. Problems should be updated and refined as more specific diagnoses are made during the
course of evaluation and/or specialty consultation. Symptoms may be placed on a Problem
List temporarily but should be replaced by the most refined diagnosis as the work up
proceeds.
9. The Overview section in the Problem List is to be used to add succinct annotations
regarding the management of a given diagnosis (problem). This may include a chronologic
history, treatment plans or workup in progress.
 Comments should be updated with the most current or accurate information,
either replacing dated information or adding to chronologic information.

Overview comments are intended to communicate with all users of the medical
record and are not be used for personal reminders or notes.

Examples of appropriate use of Overview in the Problem List:
• For a patient deferring colon cancer screening, select the most appropriate
diagnosis, “Preventive Health Care” as the problem; then place in the Overview
section, “Patient deferred the recommendation of undergoing colonoscopy.”
• For a patient refusing referral to a psychiatrist, select the appropriate
problem on the list such as “Major Depression”; then place in the Overview
section, “Patient declines mental health referral.”
• For a patient that smokes, select “Smoking” as the problem; then place in the
Overview section, “Patient is in contemplative phase of smoking cessation.”
• For a patient with coronary disease who underwent a stress test: select
“Coronary Artery Disease” and add in the Overview section, “Stress thallium
normal on (date).”
D. PAST MEDICAL & SURGICAL HISTORY
1. This portion of the medical record is a comprehensive catalog of all significant active
and historical medical problems and past procedures and surgeries. Every effort should be
made to be specific and complete with entries, including dates and appropriate comments when
available and relevant.
2. Significant active medical problems documented on the Problem List should also be
documented in the Past Medical History. The EpicCare system provides a button in the
Problem List Activity that makes synchronizing a diagnosis with the Past Medical History a single
click effort.
3. It is not appropriate for the Past Medical History to include self‐limited and temporary
problems, symptoms, inconsequential problems, remote historical problems without
continued importance, events, family history or social history.
E. MEDICATION LIST
1. All clinicians are expected to review and update patient’s Medication List at each
encounter as part of the medication reconciliation process. An accurate and up to date
Medication List will minimize medication errors and enhance patient safety.
2.Clinicians, at their discretion, may authorize designated support staff to assist in
managing the Medication List, but are responsible for reviewing entries made by their
support staff.
3. All clinicians must contribute to the accuracy of Medications Lists. This is accomplished
in a variety of ways including the specification of an end date for short term medications (finite
period of therapy), and marking all chronic medications as long term using the “push pin” in
the medications activity. Also, the Medication List should be scrubbed of duplicate entries
whenever they are identified. In addition to all active acute and chronic medications, the
Medication List should include PRN medications (available for use, even if not being used
currently), chronic over‐the-counter medications, vitamins, supplements and homeopathic
remedies.
4. Prescriptions written by any and all providers (whether or not they are in the AAHS)
should be incorporated into the patient’s Medication List.
5. Associating diagnoses with medications is highly recommended. This help clarifies the
intended use of the medication, and also helps with the process of prescription refills.
F. ALLERGIES
1. The ALLERGIES list must be current and accurate at all times. Only allergies, reactions and
intolerances to drugs and foods are to be documented in this list.
2. Entering the specific reaction is required.
3. Multiple entries of drugs within the same class are usually better represented by
entering the drug class itself in favor of the specific drugs (e.g. enter “Penicillins” rather
than listing amoxicillin, Augmentin and dicloxacillin individually).
4. The allergy severity field is used to categorize the nature of the reaction (serious,
unknown, or side effect) and should be documented. Other specific details should be entered
if known and appropriate.
5. Environmental allergies (tree pollen, hymenoptera, etc.) should be documented in the
Problem List and not in the Allergies activity of the EMR. However, allergies to extracts used
to treat allergies (e.g., hymenoptera extract) belong in the Allergies activity.
G. ELECTRONIC NOTES
1. Be concise. There is a temptation with electronic notes to populate them with lots of
information already contained elsewhere in the EMR, and as such the size of the note tends to
grow.
 It is important to strike a balance between too little and too much information.
Too little information may impair patient care by excluding important items. Similarly, a
voluminous note may impair patient care by burying the pertinent information to such an
extent within the extraneous matter that it is not seen.

For the most part, if data is already in the EMR and is not directly pertinent to
decision making, it should not be included in the note specifically. Instead, for
example, one could say, “Lab data reviewed and normal” rather than including a long list
of normal values.
2. Remember that you are responsible for everything in your note. Be sure to proofread each
note generated by the use of a template to ensure that it is a true representation of services
performed. For example, you want to avoid documenting a complete Review of Systems for a brief
encounter where one was not performed
3. Copy Previous (“Copy Prev”) is a popular Epic‐based function used for documentation, but
it can cause problems. It may bring in previous documentation that is incorrect or not
appropriate for the current note.
 A good feature is that it will refresh any SmartLinks that were used in the original
note. Nonetheless, it is imperative to take extreme care in proofreading and making
appropriate edits for every note that is created in using the Copy Prev function.
4. Copy and Paste is a Windows‐based function that acts differently than does “Copy Prev”,
and its use is generally discouraged.
 The most important difference is that it will not refresh Smart Links (so, for
example, it could bring yesterday’s vital signs into today’s note). As with Copy Prev,
the use of Copy and Paste makes it imperative to take extreme care in proofreading and
making appropriate edits for every note created in this way.
5. Smart links are also very popular, but can bring in the wrong information. For example, a
SmartLink could erroneously pull in a 3 day old lab value that makes it look to be the current
day’s value. Please, ensure that any that you are including in your templates are providing the
correct up to date information.
6. Select the correct note type. There are a variety of note types to choose from when
generating notes in Epic.
 Erroneous selection of a note type can have unintended consequences
o An example of an incorrect choice is when a consultant selects a “Consult Note”
type when making rounds on a patient subsequent to the initial consultation. That
follow up note then files in the Consult tab as an additional consultation, where it
is likely to be overlooked because we would look for it in the Progress Notes tab.
o Another example of an erroneous not selection would be if you select the Progress
Notes type for your H&P. In that case the system will not recognize that an H&P
has been done and will place it in the Progress Notes section (additionally, this
would create a chart deficiency).
The correct note type must be selected so that it is filed properly and can subsequently be found
where expected:
Type of Note Desired Select this Note Type in Epic
History and Physical H&P
Interval H&P (pre‐op) H&P
Consultation Consults
Discharge Summary D/C Summaries
Any follow up note Progress Notes
(Note that the Progress Notes type is to be used for several different kinds of
notes: daily rounds follow up consult notes, etc.)
Brief post‐op note Brief Op Notes
Full post‐op report Op Note
Delivery note (Not C-sections) Procedures
Procedure reports Procedures
H. FYI ACITVITY
1. The FYI activity is a way to flag information that is stored at the patient level. As such,
that information appears each time the patient chart is opened, regardless of encounter
type (hospital, office, or other).
2. The information placed in FYI serves as a communication tool between departments. The
content can be seen by users in Registration, Financial, Clinical, and Release of
Information areas.
3. There are currently 23 categories built into the FYI activity that can be selected for
flagging (e.g., History of Violent Behavior; Research – Cardiac; MRSA; MAPS suggests
evidence of diversion or addiction, etc.).
4. Do not use this as a general communication tool because it may be seen by personnel for
whom the information might be inappropriate or should be restricted.
5. It is important to deactivate flags when they are no longer relevant or appropriate (e.g.,
patient is no longer in a research protocol). Keep in mind however that even though it
may be deactivated, the flag can always be seen by selecting “Show inactive flags.” So even
though the flag can be hidden from view, it truly is a permanent part of the record.