Our share documentation plan is evolving. We are working on developing a shared core history. This core history recalls for all users "where possible" but we are still working on defining that. All users will be responsible for clarifying and updating all entries. I know this is going to be tough going the first few times around for a pt but over time will get better and better.
Things we know: eliminate "navigation" entries where you get a yes or a no but there is no comment. Train all caregivers that any answer yes or no must have a comment including dates and brief treatment details. Allow departments to have a specialized history that is more detailed than the core history and recognize that some of that information still must be reviewed in the history panel and won't be directly recalled into caregiver documentation. -----Original Message----- From: Grolla, Cindy [mailto:[EMAIL PROTECTED] Sent: Saturday, March 31, 2007 6:52 PM To: Deignan Marianne; Meditech L Subject: RE: [MEDITECH-L] Sharing documentation of patient history. Sharing theEMR Please post responses as we are struggling with Standardized PMH as well. We are implementing this PMH data collection in our clinics now and that information will be flowing to the EMR as well. The question our doctors always bring up is who corrects the information? The nurse does the initial data entry, the doctor interviews the patient and gets more detailed information or finds out the information entered by the nurse is incorrect. Who goes in and corrects the information - either in the PCS assessment or the PCM Physician Doc tool. Cindy Grolla, RN Clinical Project Leader Northfield Hospital Northfield, MN Phone: 507.646.1209 Pager: 507.645.1475 Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure and/or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. -----Original Message----- From: meditech-l@MTUsers.com [mailto:[EMAIL PROTECTED] On Behalf Of Deignan Marianne Sent: Tuesday, March 27, 2007 11:42 PM To: Meditech L Subject: [MEDITECH-L] Sharing documentation of patient history. Sharing theEMR We are live with PCS and about to go live with online provider documentation through PCM. Out PCM templates include Patient History. This history is shared but does not overlap 100% (or even close. much more history is tracked in queries in PCS than is PCM) to the patient history tracked in PCS that shows in the EMR. We are coming to realize that the EMR history section is going to contain a mix of provider and nurse collected information but from the first line view you can't tell who documented the information. Is anyone else planning for this dream state where providers and nurses share information but then encountering discomfort when you realize that sharing means sharing? Marianne Deignan Berkshire Health System BHS CONFIDENTIALITY NOTICE: This e-mail communication and any attachments may contain confidential and privileged information for the use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please notify Berkshire Health Systems immediately by e-mail at [EMAIL PROTECTED] and destroy all copies of this communication and any attachments. =*=*=*=*=*=*=*=*=*=*=*=*=*=*=*=*=*=*=*= To subscribe or unsubscribe to the meditech-l, visit MTUsers.NET. To check the status of the meditech-l, visit MTUsers.NET. For help, email [EMAIL PROTECTED] Visit the MTUsers WikiPedia at MTUsers.NET/mwiki ______________________________________ meditech-l mailing list meditech-l@MTUsers.com http://mtusers.com/mailman/listinfo/meditech-l BHS CONFIDENTIALITY NOTICE: This e-mail communication and any attachments may contain confidential and privileged information for the use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please notify Berkshire Health Systems immediately by e-mail at [EMAIL PROTECTED] and destroy all copies of this communication and any attachments. =*=*=*=*=*=*=*=*=*=*=*=*=*=*=*=*=*=*=*= To subscribe or unsubscribe to the meditech-l, visit MTUsers.NET. To check the status of the meditech-l, visit MTUsers.NET. For help, email [EMAIL PROTECTED] Visit the MTUsers WikiPedia at MTUsers.NET/mwiki ______________________________________ meditech-l mailing list meditech-l@MTUsers.com http://mtusers.com/mailman/listinfo/meditech-l
