Electronic Health Records For Dummies

Visit documentation goals

Make your patient care tasks official by properly documenting them. After you have the EHR up and running, you’ll find that many of the documentation responsibilities are shared throughout the practice (thank you, automated forms!). But for now, you’re still living in a paper world.

Set up some documentation goals by thinking about how, exactly, the EHR is going to help you avoid some of the pitfalls you have experienced by reviewing and analyzing what you and your staff do on a given day. Here are some things to think about when you are setting documentation goals:

What information needs to be documented in the presence of the patient and what can be documented in another location at another time?

How can information entered by the nurse, medical assistant, or other care team member help the overall visit documentation?

What are the benefits of performing POC documentation for the practice, provider, and patient?

Do you think interaction between the provider and patient will improve when documentation uses a computer? How?

Could the new documentation process negatively impact the office visit for the patient or the provider?

How will the provider’s office life improve if POC interactions are documented using the EHR?

How can computerized documentation improve efficiency?

What templates can be created to document standard visits or key clinical information?

What visuals might the provider share with the patient such as changes in trends for lab values ...