Save Time With These EMR Tips
It’s ok to copy and paste, right?
Maybe. The answer depends on what you plan to copy and paste.
Most EMRs have a function where past information will auto-populate into the current medical record. This can be a useful timesaver, especially in the history section. However, you must be aware of the risks associated with this action.
One place to watch is the current medications list. Some EMRs will automatically carry over every medication the patient has previously reported or prescribed by your clinic. Sometimes a patient will have two or three pages of medications listed. It will show meds they are no longer taking, and fifteen or twenty copies of the same medication and dosage. This is time-consuming to sort through and could possibly lead to an error or confusion regarding the patient’s medications.
Another area to consider is the HPI. Usually, the more detail in the HPI, the better. It is important to paint a clear picture of the patient’s complaint. However, if you are copying from an old chart, that information may be outdated. For example, I have seen “patient fell on ice one week ago” documented on every chart for a patient from December to July.
Don’t forget about the exam. You can copy from a previous chart if the exam was exactly duplicated and the findings were the same. Be careful! The best practice, in this case, is to document the exam findings every time the patient is seen. It doesn’t take a great deal of time, and it ensures the accuracy of the record.
Pulling information forward from a past visit can be a useful shortcut, but only if the information is carefully verified and accurate.
As mom used to always say, “Check yourself before you wreck yourself.”
To your success,
Kelli Rain, CPC, CPMA
Director of Coding
