[MUSIC] Hello, and welcome to this course. We are going to talk about electronic health record features. In this lecture, we're going to cover what happens when a provider calls for our help with technical issues during their workflow,. We're also going to talk about why correct documentation is critical from a patient safety perspective. And then we're also going to talk about just what happens when we need assistance during the ordering process. So why does good documentation matter? Well, it's very important from a patient safety perspective. It facilitates data integration and cross collaboration amongst many, many individuals, whether it's a clinician, a staff member, or a downstream system. It also reduces the need for unnecessary tests and/or procedures. And it also, again, just maintains good communication with everyone involved in patient care. We are going to breakdown the ordering process because everyone plays a role in this. And the information that a front desk staff member enters is vital to the information that a medical assistant sees to what the nurse or the doctor will see. So we want to make sure that during the appointment scheduling process, that the front desk staff member is getting all of that demographic data for the patient. Because we need to make sure that certain things in the chart are appropriately documented so we can streamline patient care. Or even from a screening tool perspective, we want to make sure all of those things are working so that when a patient comes in, that they'll either, a, have the best possible experience from a patient care perspective. Or if they screen for something positive, they may need to have a different procedure done. So all of those things are very important in this process. And we also want to make sure, let's say when the patient comes to the clinic or the hospital, that we document the appropriate weight. Because we have a lot of weight-based medications that are dependent on getting this information correct. And lastly, we also want to make sure that vital signs are documented appropriately. Because again, we want to make sure that we're not ordering tests that aren't needed, nor are we prescribing medications to patients that they don't need. So when you think about putting in an order, what goes into that? So if you have a user that didn't enter the proper order, sometimes they're going to need your help to actually correct that. So for example, you may not have the right warning that shows up when an order is being placed in the system. So for example, if you have a patient that has an allergy to a medication, we need to make sure that that's showing up appropriately so that we don't inadvertently cause the patient harm. You also may have an issue where I have a patient that comes in from outside and they have a paper order that they need to get done at your facility. We have to make sure that that front desk staff member of the person that's helping them enters that information correctly. So one of the really big examples that we often see from an outside person coming into an organization are imaging studies. So when that happens, what's so important in this communication process is that a lot of times we have third party systems that are integrated into the EHR. So we have to make sure that things like X-rays or MRIs have the correct information documented. Because if that isn't entered right, then that reconciliation process that needs to happen from that downstream system or the third party system can't happen. And if we don't order the procedure correctly, there is a lot of steps that have to happen in order to fix that. And you have to not only look at it from the perspective of fixing it in the EHR, but your help may also be needed to talk to that third party vendor as well as any other system to be able to correct that for that patient. Then when we think about just working on patient care is not just about making sure the orders are put in right, but it's also about notes in consults. So if we have a provider that's coming from a different area to a certain unit, we have to make sure that that ordering process works, that the communication goes through appropriately. And that from a note perspective, that all of that information is documented correctly. So again, if let's say that note wasn't built properly, you may get a call because charges are often associated with notes, especially consult notes. So if that wasn't documented or built correctly, your help will be needed in order to figure out which team do you need to work with to get this resolved for that patient before they're discharged. You also will need to work on trying to figure out if you had to work with another team from a communication perspective. Meaning if that order is supposed to trigger a page, let's say, to that doctor's phone, did that go through appropriately? So those things are very, very important to think through as it relates to handling those phone calls. And you also may need to walk a provider through how to actually link the order for that consult with the note that they put in. So that is also another important process that relates to billing on the back end. And the other instance that can happen is if we have a note that's written on the wrong patient, and you will get a phone call for this very, very quickly. Because if we don't resolve this, that can definitely cause an issue from a patient care perspective. And this does happen quite often, where you'll have a senior and a junior, or you may have multiple people with a very common name. So it's going to be really important for you to work with the clinician or the staff member to resolve the error with having that incorrect patient information or whatever encounter that you're looking at. And you'll also have to coordinate with the provider as well as the downstream system. And when you think about this, you're thinking about the registration perspective, or billing, or anything related to the identity of that patient. You have to make sure that you're working with all of those systems to get the right information. Because again, when we think back to the beginning and we're looking at the benefits of having an EHR. We know that from a reporting perspective, from a compliance perspective, all of those things are critical in ensuring that we're documenting the right information and sending that out to the appropriate bodies. So let's recap. We discussed why it's so important to enter the correct details when putting in an order. And then we also talked about different scenarios that can occur that will require your assistance to help a clinician or a staff member resolve an issue, especially when third party systems are involved. So with that, thank you for watching this lecture, and we'll see you in the next one. [MUSIC]
