Correct, Complete, and Electronic
There’s no doubt about it. The explosion of information technology in health care settings has revolutionized the way clinicians do their charting. Many patient interactions that used to require the composition of full sentences are now reduced to checkboxes. Patient records are viewable by many clinicians in multiple locations as patients move through diagnosis and treatment.
That’s both the good news and the bad news. Patient’s diagnoses, test results, medications, and allergies are easier for the entire health care team to view and add to. Keeps everyone on the same page, right? Better for the patient, right? As a health care consultant assisting practices with adapting to new regulations and standards, I see many instances where documentation has been the weak link in an otherwise stellar practice.
Technology is only as efficient as the humans operating it, whether that technology is pen and paper or electronic bits and bytes. Early in their careers, clinicians learn the adage: If you don’t write it on the chart, it did not get done. Today, that maxim is even more relevant. Each entry made by a clinician to a patient’s electronic health record (EHR) not only informs his/her future efforts on behalf of a patient, it can be read and acted upon by other clinicians. If an entry is forgotten, or a box not checked, the consequences for the patient can be serious.
An EHR can generate flow sheets, decision support tools, and patient education material that can make a real difference in the ability to care for patients and meet new compliance standards. Practices that document completely and carefully at each patient visit will reap benefits now and be ready to meet future requests for legal or compliance data.