The Upside to Charting in the EHR in the Exam Room

December 6, 2016

Not sure whether you should document in the EHR with the patient in the room? Real-time medication reconciliation and accurate patient records are benefits.

The best reason to document a patient's visit in the EHR while they're in the exam room is the patient can be confident that their patient record is accurate, says Derek Kosiorek, principal consultant with the Medical Group Management Association's Healthcare Consulting Group. All of that information can be verified by the patient in real time - and that means what happened during their visit doesn't end up in some "black box," where the patient is essentially unaware of what their chart says.

Michael Lee, a pediatrician at Newton, Mass.-based health system, Atrius Health, agrees. He estimates that he's able to fully document his patient visits while they're in the room about a third of the time -on a really good day, he's able to document as many as 50 percent of his patient visits before they leave the exam room.

What helps are templates within the EHR that allow him to document a relatively standard patient visit, such as one that involves a twisted ankle, says Lee.

For more complex patients - for example, a teenager with diabetes who's acting out and experiencing muscle soreness - Lee documents those key findings in the EHR, then he goes back into the patient record later in the day to document the visit more fully.

Lee also does all medication reconciliation in the EHR while his patient and, if appropriate, their parent or guardian is in the exam room. Unlike with adult patients - who typically have prescriptions for chronic conditions - pediatrics is different when it comes to medication reconciliation, he says. As such, this task is much more of a challenge for non-physician staff.

Kosiorek says that yet another reason to document patient care in the EHR in real time is the patient can leave the appointment with a printed-out summary of their visit as well as any prescriptions and referrals, as long as their physician has a printer in the exam room.

Approximately 75 percent of Atrius Health's patients are engaged with the medical group's patient portal, so Lee generally doesn't need to print out a visit summary for his patients, he says. Pediatrics is different from other specialties on this account, too. Many of the recommendations he makes are based on common guidelines, according to Lee. On a practical level, that means parents have brought in their child with their fourth ear infection, and they don't need to know what an ear infection is.

As Lee sees it, there's really only one downside when it comes to documenting care while the patient is in the exam room. And that's when the physician forgets that their primary responsibility is building a relationship with the patient in the exam room. "If the provider is excessively focused on the computer, it detracts from eye contact and the warmth" they need to foster with a patient, he says.