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May 29, 2005 Eric Rose, M.D. Design Principles for Physician Documentationin Electronic Health Records Eric Rose, MD Clinical Assistant Professor, Department of Family Medicine and Division of Biomedical and Health Informatics, University of Washington Physician Consultant, IDX Systems Corporation /momus/infodoc.htm OUTLINE Overview of physician documentation Definition Purpose(s) Common structural conventions Review of modalities for electronic physician documentation The three dimensions of documentation tool effectiveness Questions for discussion Overview of Physician Documentation Definition—? Patient-specific information Generated by a physician Capable of being viewed as text “Physician’s Note” = the viewable end-product Overview of Physician Documentation Purpose(s)—? Inform subsequent care Inform current care (“writing-as-thinking”) Research Legal purposes Billing purposes Drive automated processes, e.g. “decision-support” (electronic-structured only) Why Should Documentation be User-Centric? The “SOAP” note The “H P” note Other Note Types Entry Modalities for Electronic Physician Documentation The three dimensions of documentation tool effectiveness Ease of note creation Data quality of the note How much of the relevant information which was obtained in the physician-patient encounter ends up in the note How accurate the information in the note is How richly imbued with meta-data it is (i.e. how much discrete data collection occurs) Presentation quality of the note Discussion Questions How would YOU design a physician documentation module for an EHR? What are some of the design pitfalls for such a function? How would you design tools for building pre-composed documents (“templates”)? Should an EHR have one toolset for physician documentation and another for other users, or should the toolset be the same across user types? Discussion Questions Can EHR-based physician documentation improve patient safety? How would y
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