Best Practices for Documentation of Notes in E.H.R.

Salem Health does not encourage use of copy or copy/paste

functionality. There are many opportunities when copying and pasting
to do the wrong thing, placing a patient’s safety at risk. Authors are
responsible to validate the accuracy of their own notes, copied, pasted
or otherwise edited by the author. Once authenticated, the author is
responsible for a note’s content.

House-wide notes can contain smart phrases but users build their own
and can change or delete the smart phrases, making it impossible to
legislate their use. Furthermore, there is no tool in Epicfor tracking
changes to a note.

Definitions:
• Copy Previous---can only copy your own notes, not anyone else’s
• Copy (Windows functionality): applies to any note; can copy
anyone’s note and put it elsewhere
• “Addendum”: Epic button unique to Epic; can only apply this to
your own note; used when making an addendum or correction of
existing, exact text of original.
Note: Epic cannot turn off this button
• “Amendment”: functionality is not available in Epic
• Correction: uses a strike-through function to indicate what is
incorrect
• Deletions: cannot delete a note from Epic such that it appears it
was never there. Recommend use of the strike-through function,
same as “correction”

Smart Phrases apply only to copying functionality. Salem Health

requires the following elements to be addressed when copying a note:
*date of original
*author
*source
*what text was copied

When making a correction to a note, use strike through on the original

and enter the new information. This is best practice and is the agreed
upon method and is used by Clinical Informatics when training.

Deletions: There are situations when deletion of a note from a record is

appropriate. Usually it is that the right information has been entered
on the wrong patient and needs to be deleted from the wrong patient’s
record and entered on the correct one. Or in the case of a merging
medical record numbers, after the merge, there may be entries that
need to be moved to the correct patient’s record. Deletions in Epic do
not completely remove the note; it will still be visible to viewers,
underscoring the importance of deleting the note appropriately and
thoroughly documenting the action according to policy. Epic does not
have a requirement or button that pops-up asking why the deletion is
being done.
Recommended workflow for deleting a note:
1. Use “Addend” button
2. Enter: “Error, wrong chart”
3. Highlight text to delete
4. Click Strike Through button
5. Save
6. Deleted text is struck through and remains in the record, the
same as it did in the paper record.

Pended notes: Only the author can see a pended note. Is there a way
to move pended notes to in-basket so HIM can monitor for completion?
Need to filter by author type---otherwise, HIM will see EVERY note
Use of color fonts in E.H.R.: Need a policy that defines colors, font, and
size (“do not exceed ______”)
Need to test what the LMR prints: Lisa to check a test patient
Pharmacy uses color more than any other dept.; Laura checked
and we can use the rainbow of colors available in Windows so it cannot
be limited
Pharmacy must be using a template. Top of note is bright pink,
patient name in blue, title of form olive green, allergies in red, lab
values that pull in and are abnormal are red too.

Images from Wound Care: importing digital photos: what will this do to
printing the LMR? IOD, the release of inform. vendor, does not have a
color printers

What is ED doing now w/ their color photographs? Sending them to HIM

for retention by pt. name and date of visit