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Wednesday, November 17, 2010

Computerized Progress Notes and CPOE.




Yesterday I gave a talk about computerized progress notes to some of our staff physicians. As we are now doing 100% CPOE orders, our next phase is to be paperless at some time in the near future.

I am very proud to say that our group of hospitalist are now 100% paperless. This includes computerized physician order entries, admission and discharge medication reconciliation and now progress notes.

I started doing electronic progress notes almost a year back. It was a challenge for the first few days but now I don’t think I can go to paper again. So these are some of the advantages I see in doing electronic notes.

  • All the data you need can be pulled into your progress notes including labs, microbiology, radiology, vital signs, pathology and is updated automatically everyday.
  • You don’t have to look for charts which are never there when you need them
  • This makes it a one stop process, rather than first writing your note, place orders somewhere else and review data under 10 different tabs.
  • You can see all your patients and than sit at one place and complete your charts.
  • When you sign off, your partners can copy your notes and edit them and create a new note without inventing the wheel all over again.
  • You can improve your coding as your note has more components.
  • It is a much faster process.
  • You can create your personalized templates and use them as needed.

Next stop history and physicals, if they become user friendly.

5 comments:

Raj said...

Few drawback
If you have consultants on board then there is clearly a lack of communication. on Paper chart: I still after writing a full consult on the consult sheet write in progress notes saying patient seen and consult in Chart.

eNotes has to be more creative. Now we have 4-5 pages of info on each note not sure how much is really needed. Better interface has to be created between various doctors on the case.

Dirk Stanley, MD, MPH said...

I'm always curious - When you say "100% CPOE", do you mean there are no telephone/verbal orders?

Dirk Stanley, MD, MPH said...

By the way, you forgot to mention the nice feature : You can potentially log in from home, and finish charts in the convenience of your own house, rather than at work. :)

Irfan said...

You are right, actually I am guilty of doing that once.
Irfan

Human Factor said...

Dr Stanley,
You are right we can not be 100% CPOE orders, we have a nurse at night who takes orders. I will get back to you with exact numbers.