Role for Electronic Documentation |
Goals and Features of Redesigned Systems |
Providing access to information
|
Ensure ease speed and selectivity of infomation searches and cognition through aggre
gation trending contextual relevance and minimizing of superfluous data |
Record ing and sharing assessments
|
Provide a space for recording thoughtful succinct assessments differential diagnoses
contingencies and unanswered questions facilitate sharing and review of assess
ments by both patient and other clinicians |
Maintaining dynamic patient history
|
Carry forward information for recall, avoiding repetitive patient querying and recording
while minimizing copying and Pasting |
Maintaining problem lists
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Ensure that problem lusts are integrated into workflow to allow for continuous updating |
Tracking medications
|
Record medications patient is actually taking patient responses to medications and
adverse elfects to avert mrsdiagnoses and ensure timely recognition of medication
problems |
Tracking tests |
Integrate management of diagnostic test results into note workflow to facilitate review,
assessment, and responsive action as well as documentation of these steps |
Ensuring coordination and continuity
|
Aggregate and integrate data from all care episodes and fragmented encounters to per
mit thoughtful synthesis |
Enabling follow up
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Facilitate patient education about potential red flag symptoms track follow up
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Providing feedback
|
Automatically provide feedback to clinicians upstream facilitating learning from out
comes of diagnostic decisions |
Providing prompts
|
Provide checklists to minimize reliance on memory and directed questioning to ard in
diagnostic thoroughness and problem solving |
Providing placeholder for resumption
of work
|
Delineate clearly in the record where clinician should resume work after interruption
preventing lapses in data collection and thought process |
Calculating Bayesian probabilities
|
Embed calculator into notes to reduce errors and minimize biases in sub|ect|ve estima
tion of diagnostic probabilities |
Providing access to information sources
|
Provide instant access to knowledge resources through context specific “rnfobuttons”
triggered by keywords in notes that link user to relevant textbooks and guidelines |
Offering second opinion or
consultation
|
Integrate immediate online or telephone access to consultants to answer questions re
lated to referral triage, testing strategies or detlmtive diagnostic assessments. |
Increasing efficiency |
More thoughtful design, workflow integration, and distribution of documentation bur
den could speed up charting, freeing time for communication and cognition.
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