Intro to Clinical Documentation, Dr

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University of Missouri, Columbia *

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7566

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Medicine

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Jan 9, 2024

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pptx

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INTRO TO CLINICAL DOCUMENTATION ‣ Jonathan shirshekan, md ‣ Medicine-Pediatrics Hospitalist ‣ Physician advisor, utilization review

TEXT TODAY’S AGENDA ▸ Introduction to the multiple roles of physician documentation ▸ Understand the requirements of the admission & progress notes ▸ Learn some tricks and tips to improve efficiency ▸ Learn how to obtain relevant auto texts

TEXT WHY IS THIS IMPORTANT TO YOU NOW? ▸ Understanding why saves time and improves efficiency ▸ Average Time of Progress Note: 22 Minutes ▸ Residents of Tomorrow ▸ Attendings of Tomorrow ▸ Demonstrate Your Medical Knowledge

TEXT START OUT STRONG ▸ Be Observant: Be critical of one another’s documentation style. Find what works. ▸ Be Smart: Avoid over-documentation. More is not better. ▸ Be Flexible: Attendings--right or wrong—may ask for you to adapt. ▸ Be Savy: Explore PowerChart and use its features to your advantage

EVOLVING ROLE OF THE PHYSICIAN’S NOTE

TEXT THE DYING ROLE OF THE NOTE ▸ Original Intent: Serve as Reminder for a Single Doctor ▸ With the EMR, notes are no longer used as the source for orders.

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