Wiki coping and pasting notes

[redmond1212]

Hello,

I'm attempting to discourage caregivers from importing reams of information into their notes. Classically this is in the form of lab tables and radiology reports. On of my phyaicians was looking for support/ documentation that this adds nothing to the complexity of the encounter. We found statments reporting that assessment of a lab/study are required for credit, but there is nothing specifically stating that the importation of data alone adds nothing to the level of complexity of a note. Can anyone help me with this?

Thank you

 

[kevbshields]

Why would you not want your providers copying in the actual labs? This is robust use of the functionality of the EHR. Additionally, is that not evidence the provider reviewed the lab results? Whether it impacts coding is really irrelevent. The provider's notes are helping to facilitate the flow of information between your clinicians and thus support patient care. More importantly, it is easily accessed by the providers who look back at previous notes while treating the patient in the future.