Submitted by John Snyder, DTR, RD
Have you ever gone back and read something you wrote 6 months ago, smacked yourself in the forehead, either literally or metaphorically, and said, "What on earth was I thinking?” Now extend that time out to 1, 3, 5, or even 10 years.
Most electronic health record (EHR) systems offer tools to help providers document faster by allowing them to create prewritten text that you can pull into a progress note. While doing a brief audit for Nutritional Services, we found that about 50% of the prewritten texts contained issues that were propagated forward through sharing and copying.
The question that came out of the audit is: What is our review cycle for this information? If the answer to this question for your organization is "well, we don't have one," then it is probably the time to implement one.
So, how can you decide if you need to take time to do an audit? For that answer, in true Jeff Foxworthy style, read the following statements:
· If your EHR tools contain references to research/guidelines that are more than 5 years old, you may need a review cycle
· If your EHR tools contain unapproved or dangerous abbreviations, you may need a review cycle
· If your EHR tools contain references to specific times, such 9 am, and that note is used at other times of the day, you may need a review cycle
· If your personal EHR tools contain more than four records that say basically the same thing because you were not able to find the first one you created, you may need a review cycle
· If you could delete more than 50% of your personal texts because you either do not use them or cannot remember them, you may need a review cycle
Just say “no” to electronic hoarding. Not only will it make your job easier, but dietitians will quickly become the best friend of Information Technology (IT). The cleaner and more organized the information in the EHR, the easier it is for IT to perform updates and implement expanded functionality when it comes in from the vendor.
Thank you for reading and remember: Knowing the right answer is not nearly as important as knowing what question to ask next.