RPMS Electronic Health Record Documentation

PURPOSE:  To establish policy and procedure on documentation in the RPMS Electronic Health Record (EHR).

POLICY:  This policy establishes the expectation that every clinician will use the RPMS EHR to access and retrieve information, enter data, and respond to clinical decision support tools at the point of care. 

DEFINITIONS

•	Point of care: refers to the use of the RPMS EHR in close proximity to the patient, such as to support positive patient identification, obtain accurate and complete information for documentation, and appropriately communicate clinical findings to the patient
•	Real time: refers to use of the RPMS EHR at the time data are captured and used
•	Clinical decision making tools support interventions (“rules”): the specific alerts, reminders, recommendations, and other interventions that are triggered by a clinical decision making tools such as orders, results or a process event.

The RPMS EHR is designed to be used at the point-of-care to support timely access and retrieval of information, accurate and complete capture and documentation of information, clinical decision-making, and communications with all stakeholders in the care process.

PROCEDURE:

1.	Electronically stored and/or printed protected health information is subject to the same medical and legal requirements as the hand-written information in the health record.
2.	Entries must be accurate, relevant, timely, and complete.
3.	Extraneous text needs to be omitted.
4.	Succinct notes are more readable than verbose, lengthy notes.
5.	Plagiarized data, without attribution, in the patient record is prohibited.
6.	Standardized note titles facilitate the retrieval of specific patient information.  Issues regarding note title standardization are part of the health record review function.
7.	Appropriate note titles must be matched to note content and the credentials of the author.  This enhances the ability to find a note quickly and easily.
8.	Notes must be reviewed and signed promptly as dictated by facility policy.
9.	Viewing unsigned notes is not allowed until such time as technology provides an audit trail of the note status.  When viewing unsigned notes, there is a risk of clinical decision-making based on data that may be changed or deleted.  Limited access to certain unsigned note titles may be granted after review and approval by the appropriate medical staff committee to ensure that the viewing of these unsigned notes is consistent with ongoing patient care needs.
10.	Viewing of un-cosigned documents is determined on a case-by-case basis depending on the nature of the document and how critical the information is to patient care.
11.	Alerts, reminders, pop-ups and similar tools are used as aides to the clinical decision making process.  The tools themselves are not considered part of the Legal Health Record (LHR) however associated documentation is considered a component of the Legal Health Record.  Example:  A provider is alerted to perform a diabetic foot exam on a diabetic patient.  The initial alert that prompts the provider is not part of the LHR but the subsequent action taken by the provider, including the condition acted upon and the associated note detailing the exam is considered part of the LHR.  Similarly, any annotations, notes and results created by the provider as a result of an alert, reminder or pop-up are also considered part of the LHR.
12.	RPMS EHR users should use language that is specific, rather than vague or generalized.  Do not speculate.  The record should always reflect factual information (what is known versus what is thought or presumed) and written using factual statements.  Examples of generalizations/vague words:  “patient doing well”, “appears to be confused”, “anxious, status quo, stable or as usual”.  If a diagnosis is undetermined the documentation should clearly identify the signs and symptoms of the condition.
13.	Chart the facts and avoid using personal opinions when documenting.  By documenting what can be seen, heard, touched and smelled, entries will be specific and objective.  Describe signs and symptoms, use quotation marks when quoting the patient, and document the patient’s response to care.
14.	Document the facts and pertinent information related to an event, course of treatment, patient condition, response to care, and deviation from standard treatment (including the reason for it).  Make sure the entry is complete and contains all significant information.  If the original entry is incomplete, follow guidelines for making a late entry, addendum or clarification in the EHR.
15.	The abbreviations on the “Do not use abbreviations” list are not used in the RPMS EHR, based on accreditation standards and/or by facility policy.
16.	Copying and Pasting in the RPMS EHR – In general, the original source author and date must be evidenced in copied information. Cutting, Copying, and pasting must not be perceived as “OK” unless proven otherwise, but instead as “Not OK” until proven otherwise, Audit tracking of the copy/paste function may not be available; if so, it is recommended that copying and pasting not be utilized.
17.	There are associated risks with using copying and pasting that include: (a) Cutting and pasting the note to the wrong encounter or the wrong patient. (b) Lack of identification of the original author and date. (c) The acceptability of cutting and pasting the original author’s note without his or her knowledge or permission.
18.	Entries shall be made as soon as possible after an event or observation is made.  An entry shall never be made in advance.  If it is necessary to summarize events that occurred over a period of time (such as a shift), the notation shall indicate the actual time the entry was made with the narrative documentation identifying the time events occurred.  

•	All clinicians are expected to use the RPMS EHR as the primary means to access and retrieve information, capture data, and be guided by clinical decision support.
•	In many cases, it is expected that this use will occur in close proximity to the patient, such as to support positive patient identification, accurate and complete data capture, and appropriate communication of information to the patient. 
•	It is appropriate to print out information from the EHR for patient education purposes, as determined by the facility and/or the provider. All other requests for protected health information (PHI) should be submitted to the Health Information Management (HIM) department.