Barriers and solutions to proper documentation
1- Not knowing how to document .
-In-service programming updates from Health Information Management Services are critical. (HIMS) and through forums like this one.
2- Clinic location names can be long , non intuitive and cumbersome to enter .
-A shortcut or macro can aid and speed up entry of clinic location
3- Picking appropriate or designated note title example:
PC CBOC PROVIDER TELEPHONE CLINIC NOTE
-A shortcut or macro can take care of the repetitive and cumbersome parts of entering the appropriate note title.
4-Need to have the proper elements of a telephone note.
-A HIMS – approved CPRS template can be attached to the chosen note title.