Documenting a patient visit is one of the most important parts of a medical practice. If information is not documented or not documented correctly, it can cause huge issues for the medical facility and the patient. For example, typically, a patient enters a medical facility for a visit complaining of signs and symptoms of an ailment, an evaluation is completed, and medication is prescribed. If this visit is not documented correctly, the patient can be diagnosed incorrectly in the future. One of the biggest changes for the medical facility is the move to electronic health records (EHR). This change was because of the issue of lost and misplaced paper files. Electronic record keeping allows health care providers and systems to collect and analyze organized patient data. This helps to improve the decision-making of the clinic and allows the provider to deliver timely, effective care to the patient. There are also benefits for patients; they are allowed increased access to their personal health data, which helps them to be more active in decisions made about their healthcare. With the start of EHR, more time could be spent with the patient, and medical files became more efficient. By increasing familiarity with EHR software, the speed of data entry improves. Another important part of the HER software is documenting encounter notes. These are the notes taken when a patient visits a healthcare facility.
Chapter 4 focuses on the increased familiarity with EHR software. This chapter teaches the basic skills of the layout of the screen and the concepts of creating an encounter note (Gartee, 2017). The chapter also presents skills on adding notes, editing previous notes, and adding details. This chapter is not part of the required reading for this unit, but you are highly encouraged to review the chapter and complete the exercises that go along with it. The encounters used in the chapter are very similar to hands-on experiences that take place in a medical office, and completing these exercises as you read the chapter is very valuable. Many years ago, it would take weeks or even months for a person to obtain a medical record. To do this, the keeper of the medical record would have to locate the record and make copies of it. With the introduction of EHR, patients can access their medical records quickly at any time. There are different types of software used in the medical office today. One of the software used is the Quippe software, which is what you are using in this course to complete the exercises (Gartee, 2017). Some of the aspects of the software used in your place of employment may be different from the software used in this course; however, the concepts and skills are similar in all EHR systems. Most EHR software packages use a Medicin nomenclature (Gartee, 2016). This a numerical system that assist with the EHR software. Each vendor has a unique style of software that is used, but the nomenclature is similar. One big item to look out for is the Y and N buttons; in the past, these were used, but now many companies used round or square buttons with no letters (Gartee, 2017). There are many EHR vendors that use different interfaces, but the function is relatively the same. An example of a common function among all interfaces is the ability of a medical encoder to click on the clinical concepts instead of having to type the medical issue experienced by the patient (Gartee, 2017). As mentioned above, one change with the interface is the encounter notes with check boxes for yes and no. Most interfaces have a set up without the check boxes; most physicians prefer documentation this way (Gartee, 2017). Another important change is the use of color. Most software will change color with the recording of findings. For example, as the encoder staff records the information into the software, the color will change based on the text typed into the chart (Gartee, 2017). Medcin uses the following colors for the findings: gray, red for positive or abnormal, and blue for negative or normal (Gartee, 2017). In the input of information, there are text macros used to add text and merge findings (Gartee, 2017). There are also action buttons used on the heading with finding a text macro. When adding details, they are replaced with the option data field entry. It is important to study the parts of EHR system and understand how to use it. The main reason for the change from paper records to electronic was the speed of entry. When an individual enters the hospital, many things have to be documented. Without documentation on any of these, it is hard to prove what has happened with treatment. The time of first encounter is also known as real-time data entry or point-of-care data entry (Gartee, 2017). Most healthcare employees prefer to document information at the point of care or in real time. If this is done, all documentation can be completed before the patient leaves the office. At the point of care, or entry to the facility, the nurse will ask all questions of the patient to see what the concerns are. With the new EHR system, once the physician leaves the patient exam room, all the notes have been taken. This allows the nurses and physician time with the patient instead of long days finishing with the paperwork. This also allows the patient and other medical parties involved access to the files at any time. The speed of entry is based on the time it takes to complete the physician’s notes. As mentioned above, if these notes are completed in a timely manner, the physician can spend more time with the patient. With the use of paper files, more time was spent on completing the files than with the patient. With the advent of electronic medical files, more time can be spent with the patient instead of files. With technology on the rise, many patients are seeing this change; they are receiving more quality time and care from their medical providers. Another important aspect is accuracy; technology is more accurate then handwritten notes. Think about the last time you visited a healthcare facility. The documentation probably took place at the point of care, which allows the nurse to document all information while speaking with the patient. This makes sure that all information is clear, concise, and detailed. This also assists with record keeping because it helps to assure that files will not be lost or misplaced. The EHR system has many different vendors that work constantly to provide additional resources for clinical issues. For example, a smoker would be given information on tobacco use. Once a new patient is entered into the system as a smoker, more concepts that need to be answered will pop up. If a new patient is not a smoker, these questions will not populate. There are many shortcuts that can be used that speed up documentation at the point of care. If a patient enters the hospital and he or she has a disease that is one of the top 10 diseases for hospitalization, more questions from the EHR system will pop up. Depending on the disease, a list of places that treat the disease will be listed. These facilities can be clicked on, which provides for quicker documentation. The concept of templates and lists are also used in the EHR system, and these can save time during point-ofcare documentation. Templates are the setup of how information is presented and organized (Gartee, 2017). Lists are used to display all the information that can be found in the EHR system depending on the diagnosis or the procedure. Another important aspect of the EHR system is the review of systems (ROS) function. This is an organizational technique that reports all the symptoms of the body system based on location, from head to toe. With the new use of technology, forms are another important aspect. Forms used in the healthcare facility display the findings from the patient and allows the employee to enter the information quickly. This is essential information like dates and values. These forms are different based on the healthcare facility, but most facilities provide detailed information on the forms. A new term that is being used is otherwise normal (Gartee, 2017). This term is used during an examination when a few symptoms are found, but the patient is negative for other symptoms. By entering otherwise normal, it is clear that the patient is only presenting the specified symptoms. This speeds up the data entry because when abnormal findings are documented, the normal findings can also be documented without having to list them specifically. This type of system works best with lists. In sum, there are many positives to entering symptoms at the point of care. These benefits extend to the patient and provider alike. The chapters in this unit introduce you to EHR features that will help you to document all of the essential information at the point of care. Be sure to complete the guided exercises that go along with these chapters, as they will help you to build the necessary skills and knowledge needed in further units.
Gartee, R. (2017). Electronic health records: Understanding and using computerized medical records (3rd ed.). Boston, MA: Pearson.