Chapter 4

MEDICAL RECORD’S / GROUP B5

NOVIA ZAHROH KURNIA AROFAH LUTFIATUN N. EVI NOVITASARI SOFIA ELFIN

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 HAND – OFF
Once the patient is in the room, the provider must be notified
that he or she is ready to be seen.

In A Paper-based Office EHR (Electronic Health Record)

A system of colored Have built-in

flags or lights. functionality which
allows for a signal
to be sent to the
A personal notification clinician notifying that
by the nurse. the patient is
ready – some may
Merely by the sight of even offer an audible
the chart in the rack. or visual alert
(automated).
 DOCUMENTING
THE VISIT
1. POINT AND CLICK
Most EHR has minimize typing
by offering a “point and click”
interface for documenting notes.
SOFTWARE HARDWARE

- Checkbox Computer
- Drop-down with
menues tradisional
3 Basic Methods
pointing For entering data of the
patient encounter
This methode can be very
tiresome if interface is not user-
friendly. But, if interface is user-
friendly, this methode will be
easy, simple, and interesting.
 It would be unreasonable to think that transitioning to an EHR would have
a positive impact on any physician’s ability or attitude toward typing.
 On the contrary, some doctors who are forced to adapt to documenting this
way find themselves frustrated and terribly inefficient and also many
doctors may find this method advantageous over others.
 Many EHR products offer built-in capabilities to make typing more
efficient, by allowing clinicians to create reusable templates and macros.
 Often this can be further customized by provider, so each individual in an
2
office can have their own pre-set language and defaults. Once the doctor
begins entering data, he or she simply adds or subtracts information to
FREE TYPING
make the final note complete. This concept is known as “documentation
by exclusion.”
 The program can even assist in the development of a care plan, by offering
decision support and commonly prescribed medications for each
assessment.
  Using specialized software and a microphone, the physician
can dictate directly into the EHR and the speech will be
instantly converted to text
 The most commonly used dictation product is “Dragon
Naturally Speaking” by Nuance Software. While expensive,
3. ELECTRONIC DICTATION Dragon has a track record For accuracy and ease of use. For
health professionals, a special medical edition has been
created which includes built-in vocabulary support for all
o One final method worth considering
major specialties and sub-specialties.
o Electronic dictation
 Using software like Dragon, requires the clinician to wear a
o has been employed by thousands
headset (either wired or wireless) for every encounter, and
of physicians with significant
does take some training to build accuracy. This may create
success.
a perceived barrier to personal patient care, and raises the is
sue of where the dictation will take place.
 In order to maintain efficiency, documentation is best done
during the encounter
 EHRs provide suggestions  the clinician on how the visit
should be charged based on current CMS guidelines.

Using data entered into the note, a“level” for the visit may be
offered by the software  This cannot be achieved with
dictated or typed notes at every instance, as programs
TO CODE OR NOT TO CODE typically rely on specific data points entered by the user to
make an evaluation
The billing and The software may only know the number of historical or
method of coding with physical exam areas reviewed by tallying up the number
document impact the electronic of check boxes selected by the user.
ation record
If the note contains only free text, this will not be possible
and an accurate visit level cannot be offered.
 the promises improving beneficial to take
of health charge
advantage of
information capture and
increasing coding support
technology
revenue wherever
possible

EHR

EHR delay implementing

completely Offices
automate continue to code
the manually
process

 Input is still required by the clinician to

make the final judgment on visit level
 In the end an auditor will still hold the
clinician – not the software – to account for
how the visit is billed.
THANK YOU