I have been watching some of the threads regarding down time and have my own questions... Up until now, we re-enter everything (Vitals, Admit Assessments, Shift Assessments, ADLs, Dietary info..), basically anything that is done via interventions. Our policy is that the Electronic Medical Record is the OFFICIAL record. We do not print at discharge. There is great concern that someone looking via PCI/Clinical Review will never know that there is information "missing". If you do not know it is missing, how would you know to go look in the physical chart (or in the scanned chart) Since we plan our downtimes carefully and all our updates are done in the middle of the night, there have not been too many issues, some grumbling, but we get it done without too much cost in overtime, etc. NOW... we are heading toward EDM. This, for us, will include coded allergies and Historical meds via RXM. THEN .. we will be going to EMAR/BMV We are beginning our planning for downtime, revisiting policies etc.. for those of you already up on EDM with Nursing and/or physician documentation, what is you policy on back entry of information. Do you only enter info on patients that are admitted? Do you only enter allergies and historical medication? Who does the back entry? ED staff, Floor staff, special team? Do you leave the info only on paper? Do you put something in the electronic record to alert viewers to look somewhere else? I appreciate your time... Janice B Lisee RNC, BSN Senior Systems Analyst Frederick Memorial Hospital 240-566-3437 mailto:[EMAIL PROTECTED] <mailto:[EMAIL PROTECTED]>
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