Abstract W P293: Using Smart Phrases in an Electronic Medical Record to Document the Plan of Care and Decision Making Process During Time Sensitive Acute Ischemic Stroke Patient Interventions
Background and purpose: Documenting the physician’s decision making process in acute ischemic stroke intervention is a requirement of the Joint Commission to meeting the Comprehensive Stroke Center certification standard of involving the patient and/or family in the decision making process (DSSE. 1.). Due to the emergent nature of treating an acute ischemic stroke, the physician documentation may not clearly depict this process. The use of smart phrases in the electronic medical record (EMR) can help expedite this step while still providing individualized treatment.
Methods: Smart phrases are written by the clinician in such a way that addresses the most common clinical situations. Smart phrases lay the foundation progress note, decreasing the likelihood of omitting important patient care information. The physician can make the smart phrases a part of their own EMR template. This can save documentation time as well as meet the required documentation standards from Comprehensive Stroke Center certification.
Conclusion: The use of smart phrases has proven to be a time saver in documentation. Smart phrases have also provided a method for more standardized documentation. They aid the physician in including pertinent information necessary to demonstrate the decision making process and plan of care for the treatment of acute ischemic stroke patients. The success of using smart phrases has spread to other disciplines such as nursing and rehabilitation services.
Author Disclosures: A. Perez: None.
- © 2014 by American Heart Association, Inc.