Sunday, September 13, 2009

Structured Documentation Present

Each discipline accesses an electronic patient chart and then moves to review summary or previous visits, medications or labs, then opens and documents the new visit history and physical details along with prescriptions and other orders. The system has flags for follow up and can send postings to others involved on the team with care for each individual patient. There are signatures required and certain elements that must be posted prior to closing the chart and filing it away completed. The system has drop boxes and the ability to look up searches for specific persons such as doctors or elements within a given record.

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