OVERVIEW
Regardless of the electronic medical record (EMR) that is being used, generally speaking there are ways to improve and optimize the way in which one interacts with the medical charting system.
This guide is focused on trying to focus on the universal aspects of charting optimization so that the reader will be more effective in their ability to navigate the EMR.
LIST OF TECHNIQUES BY SECTION
Here is a list of topics that organize these basic EMR techniques by section:
- Patient lists: it may seem basic however knowing how to find, create, and optimize patient lists is an essential skill that can save a considerate amount of time.
- Smart Phrases: different EMRs may have different terminology (smart phrases, shortcuts, dot phrases, macros, etc) however smart phrases refer to EMR shorthand that can be used to save you time while charting (for example a phrase that draws in the patient’s vital signs instead of you having to go and re-type them).
- Orders: placing orders is an essential part of being an intern and requires some familiarity with the EMR system that will be sued. There are ways to make placing orders less painful in most EMR systems that is worth exploring.
- Order Sets: order sets are similar to individual orders but often times are found in a separate section then individual orders and can be significantly more sophisticated. Like individual orders, a master of order sets can be incredibly useful to the user.
- Summarizing Patient Data: there are sections of the EMR that can be optimized to summarize various types of patient data in more intuitive forms. This can include anything from the patient’s vitals to their insulin requirements and more.
- Smart Lists: smart lists can have quite a bit of utility. In essence they allow you to create a list of selectable choices that you can integrate into smart phrases that can help one’s charting efforts.
Page Updated: 06.10.2019