Specialty electronic medical records (EMRs) have revolutionized the way data are collected, collated, and delivered at the press of a button. But are you sure that the information that you are documenting within your specialty EMR is truly reflective of your Clinical, Operational, Regulatory, and Economic (CORE)* processes? Understanding how the final documentation is compiled is imperative to ensuring it is complete. Use the following checklists to better understand your specialty EMR and the steps for successful implementation.
If you are new to an EMR or simply need to review how your current EMR’s workflow pertains to work in your department, you may want to explore answers to the following questions:
- How does the EMR create the final medical record authored by the wound care clinicians and providers?
- How are signatures applied to the documentation?
- Who is responsible for the medical record requirements and what documents are part of the final medical record?
- Why are data collected in a certain sequence for a new or established patient?
- Is this sequencing constructed in the most efficient way to collect the information?
- Is the EMR missing data elements that are critical to documentation requirements, patient safety, and/or billing capture?
- If you need critical information to meet hospital documentation requirements or accreditation standards, how is this documentation addressed?
- Who maintains the software’s day-to-day functions or trains new users on the system?
Understanding how the specialty EMR is constructed and could drive efficiency in your department is the first step in choosing your specialty EMR. Remember, the goals when using a specialty EMR are to drive accountability of care; enhance care coordination through smart, efficient workflows and compliant documentation; improve care through evidence-based models; and optimize reports to drive compliance. In addition, to ensure financial success within your specialty wound care department, efficient processes must be in place to manage volume, support outcomes, and drive data/reporting. A comprehensive, interoperable specialty wound care EMR is key to the department’s success.
Read previous articles in “Advances in Skin & Wound Care” by Cathy Thomas Hess in the link.
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Cathy Thomas Hess is VP, Chief Clinical Officer for Wound Care at Net Health. She has over 30 years of experience in wound care, authored hundreds of journal articles, spoken at both national and international events, and has authored book chapters and the best-selling handbook titled Product Guide to Skin and Wound Care, 8th edition. She continues to be influential in the wound care community today and serves on the Editorial Advisory Boards for Advances in Skin and Wound Care, authoring a monthly column entitled Practice Points, and Today’s Wound Clinic.