EMR Documentation

 Instructions

Taking short-cuts in any profession can be a risk, but when it comes to health record documentation, short-cuts can impact the patient, provider, and health care entity. You are the clinical operations manager of the new surgical center.

You manage all physicians and other ancillary providers. You discover that no formal policy exists regarding “best practices” for EMR documentation.

Create a 2-3 page policy on EMR Best Practices 

• Include an introductory paragraph explaining the purpose of the policy.
• Divide the policy contents into two sections: administrative staff, and clinical staff. 
• Include at least three best practices (some of these may be the same for both administrative and clinical staff, but you should strive to identify specific best practices for each group).
• Include at least four (two for admin, two for clinical staff) common mistakes, short-cuts, etc. and how and why to avoid them.
• Your policy should use formal and professional verbiage.
• On a separate page, list a minimum of three references in APA format.