Documenting in the Electronic Health Record

If you are using Evolv, Evolv is the client’s permanent, legal record.  Therefore it is imperative that we minimize documentation errors on the front end.  Take a moment  to:

·         Ensure you are in the correct client record

·         Ensure you have the correct service event/assessment

·         Complete all areas of the form/event (do not skip fields)

·         Place N/A in text fields if you do not need to elaborate

·         You can alter your documentation up until the moment you electronically sign

·         Electronically sign your documentation once it is thorough & completed (documentation should be completed at the time the service was provided)