The wonders of electronic documentation


Despite the fact that many hospitals have not yet made the transition to electronic health records (EHR), I feel as though this is definitely the preferred means of documentation for several reasons. First, you can customize EHRs to capture whatever information your facility deems necessary. Although electronic documentation presents flexibility problems (for example, once set up, electronic documentation templates can be difficult to alter), it promotes the capture of uniform documentation. Although the cost associated with transitioning to an EHR can be a major drawback, especially in this economy, it eliminates filing loose paper and retrieving records. In discussing this topic with management, I learned that EHRs are optimal for dealing with litigation, audits, and patient care. With paper records, medical records and health information management have the burden of maintaining, filing, and retrieving charts as well as tracking the paper records’ location when in use. With the paper method, the doctors have the charts, and you may not have that immediate opportunity to document, so you forget it and more oftentimes than not, you just don’t do it. With electronic charting, I find that you just go to a computer screen view the chart and document anything right then and there. Everybody has access immediately, which makes the process more efficient and prevents lost documentation, which, for obvious reasons, is a key to exceptional clinical patient care.

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