Using an electronic health record system

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Reference no: EM131437375

Kay Carnes has begun consulting for a dialysis facility that began using an electronic health record system approximately six months ago. On her first consultation visit, she examined both the electronic and paper portions of the patient record. She found that certain portions of the patient rcord, whiich were not included in the electronic health record, were maintained in sturdy three ring binders. These binderswere labeled on the spine with the patients name and the patients treatment schedule (e.g John Doe, M-W-F, or MarySmith , T-T-S). The paper based portion of the record included signed consent forms, assessment forms, outside lab reports, history and physical examination reports from the patient's physician, or last hospital visit, identification data, CMS data collection forms, and the patient plan of care. The electronic portion of the record included data from each dialysis treatment and progress notes from the nurses, the dietician, and the social worker. On some of the older recordds in which all of the progress notes were handwritten, Kay noticed that the physicians had recorded monthly progress notes, but there were no progress notes from the physician in the electronic portion of the record that covered the past six months. Kay added the unit director, a registered nurse, about this. The director replied that all of the other disciplines were entering their own progress notes into the electronic health record during or after each patient contact. The physicians were accustomed to handwriting their progress notes and therefore did not use the computer. The physician had continued to see each patient monthly, but the chart had title documentation to indicate this after the electronic health record had been implemented.

What issues should kay address in her consultation report to this facility?

Reference no: EM131437375

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