Wiki EMR Disposition

[Mindy Davis]

We recently switched to EMR and I'm need help with understanding who is allowed to add the Dx to the disposition/Clinical Impression. I'm running across charts were the nurses/unit sectaries are adding the dx in the disposition. And I don't think that they should be. My argument is that I do my primary coding from the disposition and I don't think I should be using dx codes that have been provided by a nurse/unit sectary. Also I'm noticing that the dx that are being listed by the nurse/unit sectary are not definitive dx's.

 

[jimbo1231]

Tou are Right

M,

If you are certain that particularly the unit secretaries9 but nurses are a problem too) are adding DXs to the EMR, you do have an issue. I've been through quite a few EMR conversions lately, and pretty much things usually happen. One is the physicians either don't get enough training or simply resist proper use of the EMR. The results are the kinds of work arounds you are seeing. First I would confirm that the physicians are not documenting the DXs. The only kind of complaint approach I could see here would be if Nurse's or Seretaries were acting as Scribes. But if they were, they and the phsycian would have to document that the chart was scribed, in addition to a number of other Scribe guidelines.
I think you have an issue you need to discuss with management. If they are not responsive your facility should have a risk free method of contacting compliance.

 

[jimbo1231]

You

I have to start spell checking!

 

[Mindy Davis]

Thank you. I'm glad someone else agrees with me. This issue has been bought to Management attn's. But the nurses are fighting us on this issue. So we are researching further. Thanks for your input.

 

[ruthie72]

In our facility, the PA's are allowed to Dx and dispo, but the Dr. has to sign off on it. We never have nurses or secretaries document. Hope this helps.