Improving clinical documentation in an EMR world.
Hospitals can take three steps to ensure successful integration of clinical documentation with an electronic medical record: Engage physicians and make sure they understand the process. Make the process simple for physicians to use. Train registered nurse documentation specialists to request documentation clarifications.
Payne
Thomas
T
IT services, UW Medicine, Seattle, USA. tpayne@u.washington.edu
D003299:Cooperative Behavior; D004493:Education; D005568:Forms and Records Control / Q000592:standards*; D006751:Hospital Information Systems; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*; D010820:Physicians