We have switched to a hospital wide EMR with EPIC. Multiple documentation tabs are available including careplans,flowsheets, screening assessments,patient education and notes. The issue we have is lack of standard policies as to what is appropriate documentation for repeat patients. (I am at an outpatient wound care center.) What screenings are required, how frequently do care plans need to be updated, and nurses not writing a note when the provider sees patient are some of our concerns. Nursing documentation seems not to trigger any alerts - a poor score on a braden scale or a yes on an anticoagulant question doesnt set off any triggers.
We are interested in setting standards across ambulatory care areas, slowly we are getting by-in from administration.
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Lauren Leimbach BSN, RN, CWCA
Centrastate Med Ctr
Morganville NJ
(732)610-4583
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