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By: Dr. Devin Zimmerman, CMIO, Saint Joseph Regional Medical Center
In the paper world, the physician has to transcribe information from various places in the chart into a summary note. This transcription is done so other care providers can read key information without having to page through the chart. Examples of this kind of documentation are the immediate post-operative note and the discharge summary. With the advent of the EHR, paper documentation tasks have often been directly translated into electronic versions. This process does not take full advantage of the system's ability to gather information from the electronic medical record and include it in a pre-completed note without end user intervention....
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