Does Guided EMR Documentation Impact Clinical Practice, Documentation Compliance and Outcomes?


In a previous article entitled “Should Your EHR Documentation Templates Include Chief Complaint Specific Content,” we emphasized the importance of providing chief compliant-specific content in physician documentation templates for medical specialties that are susceptible to diagnosis-related errors. Let’s advance that concept a step further and explore what other features could be built into an EMR to increase compliance with the key drivers of clinical decision-making in the history and physical exam. For example, would it make a positive impact on patient safety if certain clinical elements in the template were highlighted to draw a greater level of awareness and compliance? For the sake of this discussion, call that “Guidance.” What does that look like? The image below is an example of what Guidance looks like in a new physician documentation application called Medical Professor™. 


Source: Hubspot

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