Using Electronic Health Records with Meaningful Use: Structured Clinical Documentation

Date Added: maj 23, 2011

Author: Michael.Young

Throughout the history of modern medicine, doctors’ handwritten clinical notes concerning medical cases have generally been circulated within a small group of primary care providers. For those physicians, a shared technical vocabulary and scribbled notes have been considered sufficient for developing diagnosis and treatment. However, as society migrates towards a digitally efficiency, this age-old system is exposing drawbacks: illegible handwriting, unavailable files, and non-aggregated data. In short, not all clinical information has been or is being properly documented.

The Department of Health and Human Services (HHS) recently issued a brief discussing an incremental approach to adopting standardized clinical documentation techniques such as electronic health records (EHRs). The brief describes an initial set of standards to enhance the interoperability, functionality, utility, and security of EHRs to encourage meaningful use of health information technology (HIT). With the consistent and unambiguous clinical documentation provided by EHRs, physicians can accurately share critical patient information with multiple users, including specialists, behavioral care providers, insurers, labs and pharmacies, public health entities, and research organizations.

The brief issued by HHS outlines the following documentation methods of capturing clinical data to ensure a standardized level of structure:

Structured Templates

Structured templates are partially-prepared notes created for the most common medical cases by a physician, clinic, or department. They work well for medical issues that fit a clear framework with a limited number of predictable variations. Structured templates present a draft for the physician to modify in order to reflect the specific patient’s condition, but also allow for a certain degree of uniformity in the data capturing process. This standardization will improve note-taking and has the potential to drive the billing process directly from the clinical record.

Radio Buttons, Drop-Down Lists, and Check Boxes

Radio buttons, drop-down lists, and check boxes provide physicians with a variety of ways to enter structured data. Drop-down lists offer options based on data in an earlier part of the chart. Radio buttons are helpful for entering exclusive data like gender or yes/no questions. Check boxes maintain and track quality of care by recording any exams performed and all questions asked. The structured data aggregated by these methods drive protocol and decision support, allow for rapid point-and-click selection, and can be embedded within sections of structured templates.

Voice Dictation/Transcription

Physicians and health care providers can dictate directly into a microphone attached to the computer to create a .wav file or audio file that is embedded at the point in the chart that the dictation took place. This method of data capturing allows for the rapid recording of a detailed description with the least amount of effort expended.

Learn More About Electronic Health Records

Standardized clinical documentation helps clinics, hospitals and other medical facilities run more efficiently and is one of the many benefits of well-implemented health information technology. Structured data entry also provides decision support at the point of care, identifies health trends, and pinpoints adverse effects of new treatments. If you need more information about electronic health record systems and how they may improve the quality of health care for your practice, contact e-MDs, a leader in electronic medical record software provision..

e-MDs offers a host of affordable, certified EHR solutions for physicians and facilities looking to modernize or enhance their services with the latest electronic health records technology. e-MDs is committed to providing affordable and integrated EHR and Practice Management Software solutions, including clinical, financial and document management modules designed to automate medical practice processes and chart management – delivering the clinical tools needed to succeed in today’s health care environment. You can find additional detailed information about all the different services and benefits an electronic health records system has to offer your practice by contacting a representative right now at 1.888.344.9836 or [email protected].

Ethan Luke. Electronic Health Records secure your electronic health records with e-MDs.