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Thursday, October 08, 2009

How to document an encounter quickly with an EMR

Electronic medical records have many advantages over traditional pen and paper charts. Speed of documentation, however, is not one of them. I have been live now on my high end electronic health record for 6 months. My first encounter on the system took place in February 2009 and took me 45 minutes to document on the system. Obviously, I would need to improve upon that. Now I do things differently, more efficiently. Here is my work flow:
  1. Schedule patient, office staff gets some clinical information
  2. Appropriate clinical templates are pre-loaded by me or staff into notes prior to patient arrival
  3. I review the templates and pre-order labs, studies, and prescriptions as I see fit
  4. When patient arrives, I perform the encounter and do my doctoring
  5. I then determine if pre-ordered tests and prescriptions are still appropriate
  6. Finally I complete the documentation, sign note, and on to the next patient.

The entire process now takes under 5 minutes and is much less stressful.

When you get an EMR, you must change your work processes to adapt.