Allergy

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Compliance and the EMR

• Thomas Payne, MD FACP
• Medical Director, IT Services

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Compliance the EMR

• Keeping track of patients on your service, or on
  your consult service.
• Attending statements what they mean, how to
  select the appropriate one, and how to complete
  them properly.
• Linking to notes by trainees (interns, residents,
  fellows).
• Medical student notes what you can and cannot
  link to.
• Entering notes yourself How to comply with EM
  requirements.
• Consults How to comply with the '3 Rs'.
• Keeping up with your documentation.

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Keep track of patients on your service, or
consult serviceCreate a list of your patients

• Set up and use a team list. See
  http//www.orcaed.washington.edu/print/powerchart/
  LM_Create_Service_List.pdf if you dont know how
  to do this.
• If a patient isnt shown on your list, write an
  order to change the attending and team assignment
  to you. E.g. Please change ADT attending
  physician to Dr. Payne, and team to Medicine E.
  I found these lists to be very accurate during my
  month
• For consult services, create custom lists, and
  allow fellow or resident to add/delete patients

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Use stamp icon presence statementsThey are
approved by UWP Compliance
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Link to resident notes rather than writing your
ownTips courtesy of Paul Sutton

• For a post-call admission note, it is sufficient
  to provide a linkage statement. Use the F3
  button to skip from blank to blank.
• This linkage statement documents your presence,
  states you examined the patient personally, and
  states that you agree with what's documented in
  the resident's note. You need not repeat the
  history, PFSH, Exam, Assessment, or Plan,
  provided that all of the elements are present in
  the housestaff note. Please be sure the
  housestaff note contains a family history and
  10-item ROS. These can be added to your
  amendment, if necessary. Also, please remember
  that you can only link to the PFSH and ROS of a
  medical student's note.
• If you wish, add a paragraph or 3 to an admission
  note, just to provide attending perspective.

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Online movies and documents cover presence
statementshttp//www.orcaed.washington.edu
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What about linking to medical student notes?

• Q. If the resident Im working with agrees with
  an excellent note written by a Medical Student,
  can I then agree with the Residents note that
  uses some Medical Student documentation?
• A. The only Medical Student documentation that
  can be used is ROS, PFSH, and vital signs. If
  your Resident has linked to a Medical Students
  note, only the ROS, PFSH and vital signs will be
  counted from the Medical Student documentation.
  If the Resident has not fully documented the rest
  of the encounter you will not have a billable
  encounter.

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Entering notes yourself

• Options (there are courses for detail)
• Clinical Note editor. 1 button templates then
  use F3 to skip through
• Powernote, 2nd generation. New, takes
  instruction and practice but my preference
• Dictate. Consider turnaround time
• If you round with your team on weekends, consider
  writing notes on rounds

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Clinical Note Editor and Powernote 2GEither
choice creates note viewable in ORCA or
MINDscape. Personal preference
Clinical Note Editor
Powernote 2G
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Consultation 3Rs

• Request for consultation
• Documented by requesting provider
• Documented by consulting provider
• Service Rendered
• History, exam, and decision making or,
• Time counseling and coordinating care
• Reply
• Documentation in a shared record is adequate
  (i.e., CC to requesting provider)
• Helpful for requesting provider to acknowledge
  completion of consult in writing

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1st R Documenting request for consultationThis
may change--under discussion
In Powernote
Use the Consults Requested section to specify
service and what you want them to do.
In CN editor
Use the Stamp Icon to insert the Consultation
Statement into your progress note. Specify the
consult service and what you want them to do
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2nd RRender service and create consult note

• For complicated initial patient, fine to dictate
  initial note
• Leave short electronic note with recommendations
• If you wish, use Dragon or directly enter
• For less complicated patients, team can directly
  enter note using template
• Attending statements added as previously discussed

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3rd RReply by adding cc recipients to notes
If you add cc recipient, note is sent to Inbox or
mailed to non-UW recipients
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Other tips for attendings

• Sign/work on notes from your office, home, or
  while traveling if you wish
• ORCA works on Mac or Windows
• Wireless available on UWMC and HMC wards
• Notes are viewable in ORCA or MINDscape
• Daily reports of notes signed by UWP members are
  sent to UWP profee coders
• Work closely with your profee coder and revenue
  cycle manager

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Compliance the EMR

• Keeping track of patients on your service, or on
  your consult service.
• Attending statements what they mean, how to
  select the appropriate one, and how to complete
  them properly.
• Linking to notes by trainees (interns, residents,
  fellows).
• Medical student notes what you can and cannot
  link to.
• Entering notes yourself How to comply with EM
  requirements.
• Consults How to comply with the '3 Rs'.
• Keeping up with your documentation.

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From UWP Retreat, 2007

• Vision
• To submit an accurate, payor-specific
  professional claim for each billable encounter
  within 24 hours based solely on the signed
  documentation and to give the provider immediate
  feedback about the coding and outcome of each
  claim.