Ehr Hysterectomy

When entering past medical history and Review of Systems into the EHR system, it can be helpful to nurses and physicians due to it auto-populating within the documentation. With this occurring in the EHR the physicians tend to only address the abnormal findings within the assessment / treatment. In other ways it is not helpful to nurses an example is “a patient stated she had a hysterectomy and when the nurse goes to type in in a template pops-up and ask what kind of hysterectomy and unless you know specifically it is difficult to choose due to it having a code attached to it.

The risk of any fields auto-populating can cause documentation becoming overlooked and the physician won’t know what to look for to complete their documentation on the patient. When it comes to ensuring that all patient information is correct and completed we must read the documentation from both the nurse and physician to see if all information is compared to be similar / same or if the documentations are missing vital pieces of information. We need to read the present documentation and make sure it coincides with past documentation if it applies with what the patient is presently being seen for.

The medication prior authorization process is an important administrative task that requires a variety of forms,
One vital piece of patient-specific information, the patient weight, is especially important because it is often used to calculate the appropriate dose of a medication. A prescribed medication dose can differ significantly from the appropriate dose as a result of missing or inaccurate patient weights. The only time a see a physician correct a prescription is if the pharmacy calls and ask if dosage is what they physician wants to prescribe or if the perception is too high of an amount for the patient and asks to change it to a different