NWPHO Introduces new EMR Documentation Guideline
Mary Huck
The use of an electronic medical record is now firmly entrenched in the outpatient arena with physicians in the Newton-Wellesley Physician Hospital Organization (NWPHO). All primary care physicians are using either Partners Longitudinal Medical Record (LMR) or Centricity (the GE electronic record). The majority of the PHO specialists have also adopted the LMR within the past year. The NWPHO’s goal is to have all remaining specialists, who have confirmed their intent to use one of the preferred electronic record systems, up by the end of 2009.
With this widespread use of the electronic medical record comes the question of what is expected of our physician users. In 2007 a representative group of PCPs and specialists met to decide what would be the guidelines for users of the electronic medical record. The recommendations of that committee have been accepted by the PHO Board and are listed below. These guidelines will ensure that the electronic record accurately captures the management of outpatients and will provide the best opportunity for seamless care.
NWPHO
Guidelines for EMR Documentation
Finalized 9/25/07
1. It is the responsibility of all EMR users to maintain the accuracy of the record.
2. All outpatient notes must be in the EMR.
3. EMR users must e-prescribe whenever possible.
4. EMR users must update problems, medications, procedures and allergies relevant
to their practice at each visit on the patient’s EMR face sheet.
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