Volume 1

Clinical Documentation and Strategic Considerations for the EMR

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The biggest challenge with clinical documentation and the electronic medical record (EMR) is achieving a balance between the technology demands and the need for physician input to ensure that, with the right input, the system produces useful, high quality information. Involving the medical staff in the process from the beginning is the only way to accomplish this operational goal. Furthermore, understanding what matters to the physicians for patient care, and for their own practices—and joining this with what the hospital needs for care, reimbursement, research, and planning—is the ultimate strategic goal. Everyone, including the patient, the physician, and the healthcare organization, will benefit from these collaborations.

The biggest challenge for the executive team is working with physicians, clinicians, and other staff members on EMR implementation through the change process. Without doubt, implementation of the electronic medical record is a significant change. Solid leadership and management are necessary for a successful implementation. And effective EMR implementation is a necessary prerequisite to using technology for an organization’s competitive advantage.

Implementing an EMR is an opportune time to fine tune clinical documentation practices. Physician input regarding their documentation practices and needs, combined with clinical documentation and technology expertise, will help ensure that output from the EMR meets the criteria for high quality clinical documentation. Careful consideration of the steps to successfully implement change, combined with resulting positive impact on clinical documentation, can help the process flow smoothly, and benefit your organization.