Volume 2

Operational Challenges of Clinical Documentation and the Electronic Medical Record (EMR): An Overview

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The EMR implementation provides a framework for discussion, sharing of ideas and an opportunity to establish best practices in clinical documentation. One teaching hospital in the northeast actually combined the implementation of their clinical documentation program with the EMR implementation. They felt that the two teams, documentation and information technology, would create a synergy that would result in happier physicians with more efficient and higher quality documentation. It has only been a few months since the implementation, but so far, it appears as though they made a good decision. Template content, in particular, has been complete, compliant, and pleasing to the physicians.

Healthcare organizations are currently in different phases of implementing electronic medical records. While only a small percentage of hospitals have fully implemented the EMR, this chapter identifies some of the operational challenges that involve clinical documentation and the EMR. Included among these challenges are training physicians to use the EMR, compliance risks when physicians use copy and paste or pull-forward techniques, and the compliant and accurate use of templates.