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Rapid Implementation of Inpatient Electronic Physician Documentation at an Academic Hospital

Journal: Applied Clinical Informatics
ISSN: 1869-0327
DOI: http://dx.doi.org/10.4338/ACI-2012-02-CR-0003
Issue: Vol. 3: Issue 2 2012
Pages: 175-185

Rapid Implementation of Inpatient Electronic Physician Documentation at an Academic Hospital

Case Report

J. S. Hahn (1, 2, 3), J. A. Bernstein (3), R. B. McKenzie (3), B. J. King (1), C. A. Longhurst (1, 3)

(1) Information Services, Lucile Packard Children’s Hospital, Palo Alto, CA, USA; (2) Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA; (3) Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA

Keywords

Documentation, information storage and retrieval, software design, Electronic health records, user-computer interface, time factors, physician’s practice patterns

Summary

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.

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