Amending Patient Notes
Unfortunately, many EHR products do not provide all of the tools needed to maintain proper patient information. Indeed, some EHR systems allow the user to attach a free text note to amend completed documentation, while the specific information in the note stays the same. For example, you may enter free form text noting a change in findings, but the actual exam note still shows the original finding. All EHR processes that use specific information to display an alert for a patient will be based on the original finding, and not the free form text addendum used to refine the note. Thereby, the EHR could fail to warn you about a treatment standard, drug interaction, or emergent problem.
EHRs can be very useful and support outstanding patient services and effective clinical operations. However, practices need to closely examine how the EHR is set up and used on a continual basis to maintain the efficacy of the patient records and efficiency of the practice.
Ron Sterling is author of the HIMSS Book of the Year Keys to EMR/EHR Success. This article post was first published on Avoid EHR Disasters. He is a nationally recognized EHR expert with the information that you need to improve patient service and performance. He can be contacted at rbsterling@sterling-solutions.com.