Wiki Starting Note Day Before

[andrewsbev23]

One of our physicians wants to start his note the day before seeing the patient to streamline his services. We moved to EHR last December, specifically My Way, and it has had a negative impact on time and the schedule. He is having the medical assistants start the note for post op and wax removal on established patients the day before they are seen. He is noting the HPI and DX the day before on the established patients. I am wondering if that is okay since the note remains incomplete until the next day when they actually see the patient. Thanks in advance for any advice.

 

[tmorgan808]

I would advise against it. The system has to save the entries somehow so there would be a time and date in the system even if it is not a chart note. Taking shortcuts in regards to EHR's is a bad habit to get into. The current audit I am working on the provider said they can go into their EHR and prove when and what time they reviewed the elements in the chart note, because it looks like they were cut and pasting.