ER Electronic Physician Documentation (H&P’s)

physician documentationEnsuring that a patient’s health information is secure and easily accessible to community and hospital providers has been challenging, but continues to be a goal which we continually strive towards.

One of the critical aspects of a patient’s record is the emergency room’s provider documentation. Initially, our hospital opened with electronic physician documentation in Meditech, but later transitioned to paper t-sheets which were only available to view in hCare after the patient’s discharge. At first, we saw a benefit in the amount of time it took for the physicians to see the patients, however after a while, it became a challenge to coordinate care between community physicians and specialists who did not have easy access to the physician record. Our physicians asked that we reimplement the electronic physician ER record to enhance the flow of information between specialties while the patient is in the hospital, and improve communication to the patient’s primary care physicians.

The electronic ER record went live in late 2012 and has received positive reviews from all involved. Specialists are able to view information from home if consulted, and hospitalists and anesthesiologists are now able to prepare for pending admissions or surgical cases. Most importantly, primary care physicians are able to look up a patient’s information from their office. This is particularly useful for new referrals or any next day follow-up appointments that are sent from our ER.

If you do not have access to Meditech from your office or would like to suggest an improvement, please let us know.

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February 2013
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