Your weekly dose of wisdom from the Physicians Practice experts.
With all the useful information available on Physicians Practice, it is easy to become overwhelmed.
With this in mind, the tip of the week is a chance to reflect on some of the wisdom found all across the site. In the April 2021 slideshow on how to ensure documentation accuracy, Jennifer Frank, MD writes the following:
It's so easy to document much more than we actually did. It is also incredibly easy to document a normal exam as part of a default template. However, these acts of inclusion and omission represent a significant threat to patient safety as well as a challenge to our professional integrity as physicians.
1). Never ever use a copy forwarded note - It just begs to be wrong. It is so easy to pull in a ton of information that was accurate three months ago but which is no longer true. Are you really going to carefully edit that content to make sure it is accurate?
2). Do not use an exam template defaulted to normal - Put stops in the template function that force you to take some action to demonstrate that you stopped and reviewed the exam. If you do use a template, think carefully about what you auto select.
3). If something is abnormal, stop and document it - Jot a quick note to yourself or type in the abnormal exam into the computer. It only takes a moment and improves the likelihood that you will accurately capture the exam.