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.