Tip Tuesday #0607
Every week, we share what we call, "Tip Tuesday." These are bits of best practices to help awesome clinicians even better in documenting. We came about calling them tips because they are not anything new but simple reminders of the simple things that tend to be overlooked. We hope you find our tips refreshing.
Surveyors and auditors are beginning to develop trained eyes on EMR forms. Use your EMR visit note's designated sections when documenting. For example, document your wound care interventions and assessments on your EMR's wound care worksheet; use your EMR's MAR form to document administered medication. Not only is it easier for surveyors, QA staff and care coordinators to find pertinent information on your visit note, your EMR may have also linked those designated sections to different clinical reports.