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Electronic Health Records For Dummies by Anita Samarth, Trenor Williams

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Documenting the visit

Concurrent access to a patient’s record using an EHR enables a physician to view a patient’s information while the nurse or medical assistant is still rooming the patient. You can view records for your scheduled patients (and unscheduled patients) any time and any place you can access the Internet (for Web-based applications).

In the paper world, you’d have to flip through multiple sheets of paper to get a sense of your patient’s progress or status. An EHR allows you to navigate past encounters and cycle through prior documentation sections, such as HPI documentation. This may be useful to you when you have a patient in for a follow-up and you want to view history or pull documentation from a prior visit.

Your EHR includes a flowsheet view of certain structured data, such as vitals and common labs results. If you want to see a common grouping of information for a particular diagnosis or visit type, work with your EHR vendor to set up default views. Figure 9-2 shows a sample diabetes management flowsheet.

Figure 9-2: A sample diabetes flowsheet.

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Set up your EHR to provide automatic reminders in the exam room for when a patient is due for preventive or disease management services. This can be helpful when a patient is in your office for a reason other than disease follow-up or preventative care, but still past due for a test, procedure, or evaluation.

Generating ...

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