Electronic Medical Records (EMR) has revolutionized the healthcare industry in recent times. M any experts felt that EMR & Voice Recognition would totally replace Medical Transcription – however; th e industry soon realized that transcription has certain advantages over point & click charting and many physicians preferred to dictate notes rather than document the data at the point of care themselves.
The most critical part of any Electronic Medical Record (EMR) is the method of data entry. EMR is about aggregation of patient encounter data at the point of care in order to provide a complete, accurate, and timely view of patient information. An el ectronic medical record is not just a typed record of the patient encounter, but an extremely useful decision support tool. The da ta can be entered into the EMR via any of the two general mechanisms: direct entry by the physician using point and click templates or transcription of dictated notes. Point a nd click template indicates that each data element, which is to be inserted, requires selection, navigation, point and click process for capturing patient information.
Transcri ptions have been around for years for documenting patient encounters. A medical provider dictates the medical note into a phone or a recording device. The transc riptionist receives the dictation and transcribes it. It may be r eviewed by the supervisor for checking errors. The final co mputerized file is then either emailed directly to the healthcare provider or the file is transferred to a web site
and is later downloaded by the provider.
Each method h as its pros and cons.
Point and Clic k Templates
Most EMR systems allow providers to generate clinical documentation, by selecting variable terms from pre-structured point-and-click templates. Users simply po int and click to select appropriate choices from lists of choices to record a patient encounter. The end result w ould be a document that closely resembles a transcribed procedure note.
* Completely customizable templates. The doctor can spe cify the layout of the template, which helps him to adjust the template as per his practice & procedure.
* Provide consisten t, complete and accurate data. The chances of medic al erros are reduced since the data is documented in customised forms.
* Notes for similar t ype of exams will appear to be standard and similar
* Store / organize dat a for subsequent retrieval.
* Each click adds data elements to the database. Point-and-click systems create data that can be used to generate clinically useful reports, such as health maintenance reminders, disease management etc.
* One of the major advant ages of template based charting is the time needed to make the document available as a medical record. Since notes are created wi thin the EMR, they are available immediately upon completion.
* It tak es more time, and definitely more concentration for a physician to navigate through large data set and create progress notes using point and click templates.
* Templates must be customiz ed as per the physician