Developing an acute-physical-examination template for a Tegional EHR system aimed at improving inexperienced physician's documentation.
It is well-established that to increase acceptance of electronic clinical documentation tools, such as electronic health record (EHR) systems, it is important to have a strong relationship between those who document the clinical encounters and those who reaps the benefit of digitalized and more structured documentation. [1] Therefore, templates for EHR systems benefit from being closely related to clinical practice with a strong focus on primarily solving clinical problems. Clinical use as a driver for structured documentation has been the focus of the acute-physical-examination template (APET) development in the North Denmark Region. The template was developed through a participatory design where precision and clarity of documentation was prioritized as well as fast registration. The resulting template has approximately 700 easy accessible input possibilities and will be evaluated in clinical practice in the first quarter of 2013.
Koncern IT, North Denmark Region, Aalborg, Denmark.
Lars
L
Lilholt
Camilla Dremstrup
CD
Haubro
Jørn Munkhof
JM
Møller
Jens
J
Aarøe
Anne Randorff
AR
Højen
Kirstine Rosenbeck
KR
Gøeg
D002983:Clinical Competence; D003718:Denmark; D004282:Documentation / Q000379:methods*; D057286:Electronic Health Records / Q000458:organization & administration*; D004632:Emergency Medical Services / Q000379:methods*; D005568:Forms and Records Control; D016247:Information Storage and Retrieval / Q000379:methods*; D010808:Physical Examination / Q000145:classification*; D011996:Records; D014584:User-Computer Interface