EHR Consult: Visit Note
Strategies for Completing Visit Notes
One of the questions that physicians often ask about EHRs is how to best go about completing the visit note. Here three Vermont physicians who were early EHR adopters share their advice.
Don’t expect the EHR to change behavior. If a physician let paper charts pile up before completing them, chances are work will still pile up with an EHR. But it is easier to complete notes from home by using the EHR remotely.
- Format templates for common visits. Developing templates is a huge step for efficient documentation, EHR users say. At White River Family Practice the physicians start with common templates that they can customize to fit each one’s style of providing care.
- Do some data entry during the patient visit. To stay on time, EHR users say it is necessary to enter some information into the EHR in front of the patient. At Winooski Family Health, they try to get at least half of the note done during the visit, including prescriptions and referrals. White River Family Practice encourages staff to pivot the laptop screen so the patient can see what is being entered.
- Preformat standard advice. Routine advice and instructions to patients, which physicians repeat often, can be pre-formatted to be added to a patient’s note with a click.
There are many more strategies for efficiently completing visit notes with an EHR. VITL’s experienced EHR implementation specialists can show your practitioners how. To learn more about VITL’s services, click here or contact Larry Gilbert at 802-839-1943 or email lgilbert@vitl.net