Reference no: EM132165250

Kay Carnes has begun consulting for a dialysis facility that began using an electronic health record system approximately six months ago. On her first consultation visit, she examined both the electronic and paper portions of the patient record.

She found that certain portions of the record, which were not included in the electronic health record, were maintained in sturdy three-ring binders. These binders were labeled on the spine with the patient's name and the patient's treatment schedule (e.g., John Doe, M-W-F, or Mary Smith, T-T-S).

The paper-based portion of the record included signed consent forms, assessment forms, outside lab reports, history and physical examination reports from the patient's physician or last hospital visit, identification data, CMS data collection forms, and patient plans of care..

The electronic portion of the record included data from each dialysis treatment and progress notes from the nurses, the dietitian, and the social worker.

On some of the older records in which all of the progress notes were handwritten, Kay noticed that the physicians had recorded monthly progress notes, but, there were no progress notes from the physicians in the electronic portion of the record that covered the past six months.

Kay asked the unit director, a registered nurse, about this. The director replied that all of the other disciplines were entering their own progress notes into the electronic health record during or after each patient contact.

The physicians were accustomed to handwriting their progress notes and, therefore, did not use the computer. The physicians had continued to see each patient monthly, but the chart had little documentation to indicate this after the electronic record had been implemented.

1. What issues should Kay address in her consultation report to this facility?

2. What recommendations would you make if you were in her place?