A few assumptions are sort of best practice. For example having more than one chart open at a time. Yes with paper we have a chart open on our desk and lay another over it to answer the phone. Do you ever close a chart up with another chart (or a loose page) inside it? Of course you do, so that is not a best way to do things. IT IS MUCH WORSE with an EMR, with multiple charts open you could chart on the wrong patient VERY easily, so it is a habit we must break.
Signing the chart right away and not finishing the chart later is another habit we have to change. Billing before the chart is finished really is a no-no. Don't fight it, just bend with the flow, I think you will be glad you did. It took me awhile but now I am up to speed with all of this.
As for the superbill, we print out the "face sheet" and for three years we had our staff record the vitals on this and then transcribe to the EMR at a workstation. We used a simple (and cheap) rubber stamp to provide a place on the face sheet for the vitals to be logged in. We went without the face sheet for the past two weeks, and while the staff want to continue to enter the vitals directly into the new laptops, the Doctors have elected to continue having a face sheet, just so we have a "doodle sheet" to enter notes about tests to order, billing numbers etc. I expect we will abandon this sometime in Version 6, but for now, we will continue this hybrid model, it works for us.
