Summary
Electronic physician documentation is an essential element of a complete electronic
medical record (EMR). At Lucile Packard Children’s Hospital, a teaching hospital affiliated
with Stanford University, we implemented an inpatient electronic documentation system
for physicians over a 12-month period. Using an EMR-based free-text editor coupled
with automated import of system data elements, we were able to achieve voluntary,
widespread adoption of the electronic documentation process. When given the choice
between electronic versus dictated report creation, the vast majority of users preferred
the electronic method. In addition to increasing the legibility and accessibility
of clinical notes, we also decreased the volume of dictated notes and scanning of
handwritten notes, which provides the opportunity for cost savings to the institution.
Keywords
Electronic health records - information storage and retrieval - physician’s practice
patterns - software design - time factors - user-computer interface - documentation
