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Purpose Paper clinical notes (PCN) have been an enduring tool in clinical medicine, but are slowly being replaced by electronic medical records (EMR) in a nationwide effort to improve clinic efficiency, to enhance interdepartmental communication, and to minimize medical errors. Our healthcare center utilizes a transitional EMR that requires outpatient clinic physicians to document patient visits on PCN and to submit them to an external department for upload to the center-wide EMR. This process generates a lag period, ranging from 1 day to 3 weeks, during which PCN are inaccessible electronically. If notes are unavailable via EMR at subsequent visits, physicians are forced to search through paper charts, which may be located in clinic or at a satellite office, thus impeding clinic workflow and lengthening patient wait time. In response, we designed, created, and implemented an EMR interface or electronic note (EMRI) that mimics the prior paper template. Physicians use a portable laptop computer in the exam room and directly upload their findings to the patient’s center-wide EMR, reducing the time required for follow-up charting. We are evaluating the workflow of the pediatric rheumatology outpatient clinics and assessing patient perceptions as we transition from PCN to a complete EMR system.

pediatric rheumatology online journal

Implementation of an electronic interface for the documentation of pediatric rheumatology medical records improves physician and patient utilization of time in clinic