Page 8 - Part 2 Navigating Electronic Media in a Healthcare Setting

SVMIC Navigating Electronic Media in a Healthcare Setting

Copying information from a prior note and pasting into a new note
can result in notes which are identical for multiple office visits. This

is particularly risky for a physical examination which may have

changed since the prior visit and now may not reflect the
complexity in the patient’s condition.

Using this function may also result in irrelevant over-
documentation perpetuating outdated or incorrect information and

produce voluminous progress notes that obscure important new

information. Copying and pasting entire X-ray reports or lab data
into notes only adds to the problem.

It can also result in entries with errors that are repeated in multiple
office notes, essentially becoming “immortalized”. In other words,

the mistakes that were made in prior entries are carried forward.

This is particularly apparent in typos and non-standard
abbreviations that are carried forward from the initial entry.

Auto-Population

Auto-population, like templates, allows the EHR system to prefill

information in specific areas of the medical record as a means of
creating a shortcut or improving the efficiency of the

documentation process. The practitioner must be aware of those
areas of the medical record that are auto-populated in order to

know what information will need to be reviewed and either verified
or corrected prior to signing the note.

Most EHR systems contain checkboxes for the practitioner to use

to select symptoms and findings that reflect the patient’s condition.
These checkboxes are often connected to templates. When a

template is selected, certain fields in the EHR are automatically
filled with the “canned” or preselected text. This text can be

diagnosis-specific and the checkboxes may be pre-selected based

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