Documentation and the EMR

Most healthcare organizations today are in some state of evaluating, implementing, or upgrading information technology related to patient records. Whether it is computerized patient order entry, optical disc imaging, or implementation of a complete EMR, these activities all present further opportunity to build the hospital-physician relationship. While initial implementation can be burdensome for everyone, so long as appropriate training and control measures are in place, the resulting health information collection process should improve care, improve communication, ease the work of the physician, and make the patient record keeping process more compliant for the health care organization.

As health care organizations work towards implementing an electronic medical record, concerns about how clinical documentation is reflected in those records is growing. Some of the issues that need to be addressed include the compliant use of templates, physician input into content and process to be used for collecting their documentation during the development process (not after it’s over), and the ability to integrate different components of the record to create an optimal record for each patient. The book addresses these issues as they relate to achieving high-quality clinical documentation.