This option calls for entering patient information as they come in for a visit. The chart is pulled for the visit and the physician or nurse can enter the data during the visit.
Susan Andrews, MD, Murfressboro, TN, says:
"We found that extracting the information the first time the patient came in with
EMR in use worked well. If you have a nurse who is good at it, let her do
it, or the physician can do it. A combination can work as well. We did it both ways, and one doctor dictated with the transcriptionist putting it straight into the right part of the chart.
How it gets done is less important than getting the information in the right place. What code is picked is not that important either. The coding is for billing purposes, and having a slightly "wrong" one does not impact patient care."
Pennie Marchetti, MD, Stow, OH, says:
"I'm doing it [this] way. It slows patient flow down if I do it during the patient visit. I was running up to an hour behind. Instead, I've been entering the old info in the summary field (problem list, med list, etc.) usually at lunch and at the end of the day on the day the patients are seen. It adds about one to two hours to my work day, depending on the number of older, complex patients I see that day."
Physician-entered
As patients are seen