Published by the California Healthcare Foundation in April 2010, documents provide information and guidance on techniques to effectively document clinical information:
“This issue brief on clinical documentation techniques is the second in a series of tactically oriented publications based on lessons learned through the California Networks for Electronic Health Record Adoption (CNEA) initiative. With electronic health records (EHRs), chart information can be accurately shared among multiple users, including specialists, behavioral care providers, labs and pharmacies, insurers, public health entities, and research organizations.
Clinical documentation options available to users of most EHR systems are explored in this issue brief. The various structured and free-form methods are described, along with their advantages and disadvantages and the impact on efficiency and effectiveness of EHR use. The documentation methods include:
- Structured templates — partially filled-in notes created in advance for the most common types of cases for the practice or physician;
- Radio buttons, drop-down lists, and check boxes — tools to narrow choices for easy note-taking;
- Manual data entry — writing notes in free text through a keyboard or stylus; and
- Voice dictation/transcription — creating an audio or .wav file embedded in the chart.
(This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a
specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.)