Electronic Medical Record Documentation

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to change the entries of other providers when those entries are in need of an update (e.g. refining the diagnosis), are outdated, in error or are not consistent with guidelines.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.