As practices start the migration from paper to electronic health records (EHRs), many have found that the transition is easier when all of their charts are organized in the same manner and incorporate templates to reduce handwriting and facilitate clear, concise documentation.
Most medical practices, especially small offices, still use paper-based medical records. Experienced physicians often experiment with different formats, forms and structure of their charts. It is also not uncommon for physicians in the same practice to adopt different styles of documentation and preferred forms. This can create challenges for cross-covering physicians and support staff, and could complicate transitioning to EHRs.
Therefore, even practices not currently considering EHRs may benefit in the long run from re-evaluating their documentation methods. At the very least, groups may find ways to improve the efficiency of documentation and adopting a structured template for notes may ease the transition to an EHR. Even if not all of the information from paper charts moves into a new EHR, having information in structured fields will ease an eventual transfer.
Some physicians may resist adopting new forms introduced all at once, so one strategy might be to phase in the new forms over time. For instance, start by updating problem lists, medication lists and health maintenance logs in the chart, as these are typically the first pieces of information entered into an EHR. Formatted progress notes may be a larger leap for physicians who currently start each note with a blank piece of paper. However, templates reduce the need to write, support adequate documentation for coding purposes, and may allow the other members of a practice team to manage a treatment/follow-up plan without interpreting handwriting.
ACP has assembled a set of forms to download and customize online. Several of these forms were designed to work together (indicated by an asterisk on the Web site). If you have a particularly useful form to share with other ACP Members, contact the Center for Practice Improvement & Innovation.