At the present time, the number of clicks necessary to fill out a chart is endlessly time consuming and non-productive. The cost per click is now being calculated (see my prior blog) and quantified. The work flow is slowed down and there is a real-not imagined- price to pay.
One solution is to create an auto-flow sequence that is tunable by site or provider and that comfortably guides the clinician from one area of the chart to another in a logical-customary- sequence. If an out of sequence entry is desired, this should be easily accomplished. A system with automatic guidance will eliminate the need to figure out where should one go next, especially if one is interrupted. When it is acknowledged that one area is complete, it then moves to the next area when documentation is continued or resumed. Once the area is completed, the list shrinks. Your favorite click might be auto-sequenced.
An example sequence could be...
- Vital signs
- Triage sheet
- Past medical history
- Nursing notes
- History and PE in logical order
- Medical decision making
- CPOE
- Lab and x-ray results
- Clinical course
- Final diagnosis
- Disposition
- e-Prescribing
- Patient education
- Follow-up
- Review nursing notes
- Sign the chart
Navigation would be significantly simplified. The provider can always go to any area directly and in any order. Nursing notes might be reviewed, if easily accessible. Training would be simplified and hopefully stress-reduced.
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