Getting Ready for the Electronic Medical Record

The documentation and record keeping of a practice is critical on many levels. Besides being the record of care, it provides for:

• Accountability
• Legislative Requirements
• Communication
• Appropriate levels of confidentiality
• Funding and resource managment
• Risk management through documentation

The characteristics of well-structured medical forms and documents repositories

• Concise documentation through appropriately sized fields and elements within the forms
• Methods to review previous documentation through navigational clues, such as chronological ordering and matter separated by subjects (tabs)
• Handling the need to evolve in a controlled way – in response to new systems, legislation, practices.

In order to achieve these characteristics, records and documents need:

• The documents are contemporary
• The documentation is factual and authentic (including signatures)
• The documentation is based on evidence and observation (high accuracy)
• The entries are timed and dated appropriately and in a timely manner
• The details are inclusive of the planned care provided and actions taken
• The documentation is a complete and available record

As described by the World Health Organization: Guidelines for Clinical Documentation