Electronic Health Records For Dummies

Visit documentation

Not surprisingly, there’s quite a lot of paperwork associated with each patient visit. The majority of this documentation occurs where the physician (or other medical personnel) provides care because the (often, one) paper chart is usually with the patient. What once was documented on paper is now documented using your EHR software. Aside from spending less money on paper products, you and your staff will have to maximize your functional mobility and make the most accurate notes for each patient visit. But first, think about how you perform documentation.

Providing documentation using the EHR isn’t just about using less paper, it’s also about providing a better quality of care for patients and a better quality of life for providers and office staff.

Ask yourself and your team some initial questions to define documentation patterns and preferences. Doing so can help you determine how you can best use the EHR and associated hardware devices (such as workstations) and mobile computing devices (such as laptops or tablets). Here are some questions to get you started:

What portions of each patient visit are documented?

Who documents patient information?

What is documented while a patient is being placed in an exam room?

• Recording vitals

• Medication and history review

• Protocol orders and results (for example, a urinalysis for an OB patient)

What is documented ...