February 15, 2021
EMR Documentation – How are we doing?
Accurate – Electronic Medical Record (EMR) documentation assists us to connect the care we provide in the Emergency Departments to the inpatient units. It also is the source of truth for Allergies and Alerts.
Graphs 1 to 5 – EMR Documentation Performance – Emergency Departments and Short Stay Units.
Like or Dislike?
What we like:
- A high percentage of of patients are having their Allergies checked during every episode of care.
- The Short Stay units are not recording incidents where cannulas are overdue for removal.
What we would like to see improve:
- The percentages of patients who are having the COVID Nursing screen completed at shift change over.
- The percentage of patients who are having Alerts checked each episode of care.
- The completion of appropriate risk assessments in the Short Stay Units.
Supporting Documents
EMR Documentation – QRG
EMR Documentation – TOTW
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