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  • Promises and Challenges of the Electronic Health Record (EHR)

  • How to Write Orders

    • A.A.D.C. Vaan Dissl

  • SOAP Note or Daily Progress Note

  • Discharge Summary/Note

  • On-Service Note

  • Off-Service Note

  • Bedside Procedure Note

  • Preoperative Note

  • Operative Note

  • Night of Surgery Note (Postop Note)

  • Delivery Note

  • Outpatient Prescription Writing

  • Shorthand for Laboratory Values

Chapter update by Steven A. Haist, MD, and Leonard G. Gomella, MD


The EHR has been a major disruptive change in healthcare over the last 20 years. The adoption of the EHR across the United States was accelerated by the HITECH Act passed by Congress in 2009. EHRs are very expensive, often costing academic medical centers and healthcare systems hundreds of millions of dollars. Besides the actual cost of the EHR, many hours of training staff and physicians are required, often affecting productivity during implementation. Once an EHR is in place, physicians spend many additional hours each week documenting in the EHR compared to before implementation. For many physicians, the EHR in the ambulatory setting, and to a lesser extent in the hospital, is an obstacle to optimal communication with the patient, because physicians will spend a great deal of time during the encounter entering information in the EHR and less “face time” with patients. Additionally, some patients perceive privacy concerns. And lastly, in the past, medical students were excluded from using the EHR. This changed recently when the Centers for Medicare and Medicaid Services (CMS) allowed the use of the student note for the documentation used for billing purposes. Organizations such as the American Medical Association have promoted EHR training for students, and most academic centers now provide that resource to students.

For all of the recognized drawbacks, the EHR appears to be improving the quality of patient care. Vaccination rates increase, as do the use of deep venous thrombosis (DVT) prophylaxis; rates of guideline-based treatment of hypertension increase, and increases in the rate of proper use of antibiotics have all resulted with the implementation of the EHR. There is improved coordination of care between providers in the same healthcare system and across different healthcare systems through health information exchange (HIE) programs. Additionally, patient participation in their own healthcare as a result of HIE is enhanced. Computerized provider order entry (CPOE) was initially intended to address errors that were inherent in handwritten medication orders. Eliminated are medication errors that resulted from illegible handwriting and misspellings, as well as a decrease in errors related to the wrong dose being administered and the ability to send alerts and warnings regarding drug interactions and medication allergies. CPOE for laboratory tests, consultations, and procedures has also provided benefits. When coupled with clinical decision support systems, CPOE can restrict the ordering of expensive laboratory testing except when indicated and can help ensure best practices are followed, such as DVT prophylaxis ...

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