Physicians and providers may now use abbreviations in the principal final diagnosis provided that the diagnosis is an available choice in Epic. A practitioner is not allowed to enter his/her own abbreviations.
This change in medical records documentation requirements comes at the recommendation of the five Legacy Health medical staffs.
Traditionally, the use of abbreviations and symbols has not been allowed in final diagnoses due to the importance of this key piece of patient information. The implementation of Epic created a conundrum in this regard: Many of the pre-entered diagnoses in Epic include abbreviations. In addition, the Epic field for final diagnosis is limited to 70 characters necessitating the use of abbreviations for some diagnoses. Also, under the former Medical Staff Rules and Regulations, a medical record with an abbreviation in the final diagnosis was considered incomplete.
With the change, this conundrum has been resolved.
To populate the final diagnosis field, check the "Principal" box next to the diagnosis in the Problem List.