Question

1. You are the health information manager at a local hospital. A physician on the medical staff does not understand how to add H&P notes to a patient's EHR. He explains that he "always used to handwrite the H&P" You explain to the physician that he can no longer handwrite his H&P notes, and you give him two options of how he can add his H&P notes to the EHR. Describe these two options. A B I

Answer 1

Every time health care personnel treat a patient, they record what they observed and how the patient was treated medically. This record includes information the patient provides concerning his or her symptoms and medical history, as well as the results of examinations, reports of X-rays and laboratory tests, diagnoses and treatment plans.

Increasingly, this information is maintained electronically in health care information systems. The practice of acquiring, analyzing and protecting digital and traditional medical information vital to providing quality patient care is known as health information management.

Health information management professionals are highly trained in the latest information management technology applications and understand the workflow in any health care provider organization from large hospital systems to private physician practices. They are vital to the daily operations management of health information and electronic health records. They ensure a patient’s health information and records are complete, accurate and protected.

Health information management professionals work in a variety of different settings and job titles. They often serve in bridge roles, connecting clinical, operational and administrative functions. These professionals affect the quality of patient information and patient care at every touchpoint ​in the health care delivery cycle. They work on the classification of diseases and treatments to ensure they are standardized for clinical, financial, and legal uses in health care. Health information management professionals care for patients by caring for their medical data.

The electronic health record (EHR) is an important advancement in health care. It facilitates improvement of health care delivery and coordination of care.

Clinical notes summarize interactions that occur between patients and healthcare providers. With adoption of electronic health record (EHR) and computer-based documentation (CBD) systems, there is a growing emphasis on structuring clinical notes to support reusing data for subsequent tasks. However, clinical documentation remains one of the most challenging areas for EHR system development and adoption. The current manuscript describes the Vanderbilt experience with implementing clinical documentation with an EHR system. Based on their experience rolling out an EHR system that supports multiple methods for clinical documentation, the authors recommend that documentation method selection be made on the basis of clinical workflow, note content standards and usability considerations, rather than on a theoretical need for structured data.

Healthcare providers documenting patient care delivery can use any of a spectrum of different documentation methods, including handwriting on paper, dictating note contents into a recording device from which they can later be transcribed and using any of various computer-based documentation (CBD) systems. Creating clinical notes, herein called clinical documentation, consists of a process in which healthcare providers record the observations, impressions, plans and other activities arising from episodes of patient care, and generally occurs with each interaction between patients and the healthcare system. The notes that result from clinical documentation are generally intended to produce an objective record of a patient’s history, physical findings, medical reasoning, and patient care; to recount the care and procedures that individual patients receive in case of potential future arbitration; to justify the level of reimbursement for given services; to determine the quality of care provided to patients; to provide clinical data for research; to apply computerized decision support algorithms; and, to allow data mining for real time process improvement and quality monitoring.

EHR system with the belief that healthcare providers should be able to choose from a broad palette of documentation methods, based on clinical workflow, document content standards and usability considerations. Three major goals for integrating clinical documentation in this way were:

    1.     that it would allow a variety of documentation methods to contribute notes to the EHR system,
    2.    that all healthcare providers could view any clinical note in the EHR system, regardless of the documentation system they use in their own practice, and,
    3.    that adoption of a specific documentation method would not become a barrier to the completeness of data within the EHR system.

Supported documentation methods include handwritten or other paper notes scanned into a digital format, transcribed dictated notes and notes entered directly into any of several CBD systems.