Rapid implementation of inpatient electronic physician documentation at an academic hospital

Abstract

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; documentation; information storage and retrieval; physician’s practice patterns; software design; time factors; user-computer interface.

Fig. 1

Example of an Admission Note template using Clinical Note Editor created by a user before free-text entry. The left and right screens are continuous. When a note is created, available system data is automatically retrieved (such as the problem list, medications, allergies, vital signs, growth parameters, labs, and radiology results) and displayed in blue characters. The major headings are highlighted in bold and the underscores indicates ‘tab’ stops where the user can easily navigate to and add free-text (displayed in plain black font). Additional system or personal macros can be inserted anywhere in the document.

Fig. 2

Example of folder structure for notes.