Having been on both sides of these discussions, let me make a few suggestions. Let the company’s representative show you how they document information. Look for systems structured around some type of an extended disease-specific SOAP (subjective, objective, assessment, and plan) note. Let them walk you through a typical simple encounter without interruption. On your initial pass, don’t focus so much on the system’s knowledge base, but instead focus on understanding the design and flow of the system, asking yourself questions such as, can you understand it and does it make sense?
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August 2011In my next column, I will discuss what to look for in documentation tools and how to make the system work for you. Please take the time to contact me with your feedback and suggestions for these columns at rodney.lusk@boystown.org. ENT TODAY
Rodney Lusk, MD, is director of the Boys Town Ear, Nose & Throat Clinic and Cochlear Implant Center at Boys Town National Research Hospital in Omaha, Neb. He has been working with EMRs since 1996.