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Treffer: A Daily Hospital Progress Note that Increases Physician Usability of the Electronic Health Record by Facilitating a Problem-Oriented Approach to the Patient and Reducing Physician Clerical Burden.

Title:
A Daily Hospital Progress Note that Increases Physician Usability of the Electronic Health Record by Facilitating a Problem-Oriented Approach to the Patient and Reducing Physician Clerical Burden.
Authors:
Sutton JM; Department of Nephrology, Indiana University Health, Lafayette., Ash SR; Department of Nephrology, Indiana University Health, Lafayette., Al Makki A; Department of Nephrology, Indiana University Health, Lafayette., Kalakeche R; Department of Nephrology, Indiana University Health, Lafayette.
Source:
The Permanente journal [Perm J] 2019; Vol. 23. Date of Electronic Publication: 2019 Jun 14.
Publication Type:
Journal Article
Language:
English
Journal Info:
Publisher: Permanente Press Country of Publication: United States NLM ID: 9800474 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1552-5775 (Electronic) Linking ISSN: 15525767 NLM ISO Abbreviation: Perm J Subsets: MEDLINE
Imprint Name(s):
Publication: Fall 2010- : Portland, OR : Permanente Press
Original Publication: Portland, Or. : Kaiser Permanente,
MeSH Terms:
Hospitalization* , Medical Records, Problem-Oriented*, Electronic Health Records/*trends, Attitude of Health Personnel ; Documentation ; Humans ; Models, Theoretical ; Patient Safety
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Entry Date(s):
Date Created: 20190718 Date Completed: 20200422 Latest Revision: 20200422
Update Code:
20250114
PubMed Central ID:
PMC6636503
DOI:
10.7812/TPP/18-221
PMID:
31314721
Database:
MEDLINE

Weitere Informationen

We suggest changes in the electronic health record (EHR) in hospitalized patients to increase EHR usability by optimizing the physician's ability to approach the patient in a problem-oriented fashion and by reducing physician data entry and chart navigation. The framework for these changes is a Physician's Daily Hospital Progress Note organized into 3 sections: Subjective, Objective, and a combined Assessment and Plan section, subdivided by problem titles. The EHR would consolidate information for each problem by: 1) juxtaposing to each problem title relevant medications, key durable results, and limitations; 2) entering in the running lists under Assessment and Plan the most relevant information for that day, including abbreviated versions of relevant reports; and 3) generating a flow sheet in a problem's progress note for any key results tracked daily. To reduce physician EHR navigation, the EHR would place in the Objective section abbreviated versions of notes of other physicians, nurses, and allied health professionals as well as recent orders. The physician would enter only the analysis and plan and new information not included in the EHR. The consolidation of information for each problem would facilitate physician communication at points of transition of care including generation of a problem-oriented discharge summary.