Trust Risk Management Services, Inc.

Many Allied Healthcare Professionals (AHPs) now use electronic medical records to document.  This has reduced issues with written documentation, such as orders that cannot be read.  Electronic records, however, certainly have their own set of issues in comparison to written records.  The inability of systems to communicate/merge information from outpatient to inpatient providers, limited fields for entries, and potential for fields being left incomplete/blank are a few of the challenges in documenting electronically. Another issue that emerges when documenting in electronic records versus written records is “copy and paste.” 

A few weeks back, we featured a 12-part blog series on documentation.  One segment, Tip #4, asked the question, “Is an Addendum or Correction OK?”  This Tip seemed to spark a lot of interest, so we thought it would be good to expand on this issue a bit more...

There are special considerations when engaging in telebehavioral health with patients who are away at college.  Here are a few considerations to keep in mind...

As a behavioral health provider, you may have patients who go off to college - either in or out of state.  This can be a difficult transition for the patient, as well as you, as the provider.   There may be some challenging issues and decisions about treatment.  A few questions come to mind...

If you have been practicing in the Allied Health space for years or are a new practitioner, you likely have heard the saying, “If it wasn’t documented, it wasn’t done.” This may have been taught in your training to enter your profession. Proper documentation is not as clear-cut as this statement, however. Documentation is critical, but there are also times when certain observations or occurrences may not be memorialized when documenting in an electronic medical record (EMR) or in written format.