Electronic clinical notes, fears, hopes and solutions!

Posted 1 June 2016 in , Business and Marketing, clinical
Paper clinical notes

During my travels, I have come across many practitioners with varying experiences of using clinical software. It ranges from good to not so good and more often than not in the Osteopathic world electronic clinical notes are a step into

the unknown. After all, many practitioners were not taught to use computers in a clinical setting.

Benefits of electronic clinical notes:

Recording patient notes electronically ensures they are legible, something that is not always the case with handwritten notes. This can be important when records need to be accessed by fellow practitioners, or supplied to an authorised third party.

Electronic storage is, increasingly, a safer environment than a traditional filing cabinet. Once a practitioner begins using electronic clinical notes, there’s usually no looking back. For those who are yet to be convinced, here are some of the benefits of recording your patient notes electronically:

  1. Where a patient is seeing more than one medical professional, electronic notes can be shared more efficiently
  2. Electronic notes alleviate the problem of illegible handwriting and can ensure that language is less ambiguous
  3. Electronic notes can require verification or validation rules to be followed, thereby reducing the instances of missing or incomplete information
  4. Copying and transmitting whole, or individual, sections of records is easier
  5. No bulky files to store, so less space required for cabinets
  6. No wear and tear occurs in records that are regularly accessed
  7. Records are protected from accidental damage, e.g. fire or water damage
  8. Records can be located chronologically and alphabetically
  9. You can report the clinical information captured during your consultations (more on this later!)

Taking the concerns out of clinical notes:

One of the main concerns I come across is due to the fact that there can be a tension between solid structure and flexible documentation during the consultation. The key is to get the right balance. So how can you do this? Well, if you are thinking about making the move from paper notes to electronic the key in my book is to reflect the current flow of your paper notes. Start with the easy wins, don’t try and re-create complex in-depth assessments (that can come later. Get the first template under you or your team’s belt so that the uptake is as smooth as possible. There may be a period of getting used to using a computer in front of a patient (a common question asked when working with our clients) but with a little practice and time it’s soon overcome. Some simple advice is to not physically put the computer between you and the patient … think of a scene when visiting a bank manager sat behind a big desk! It’s neither good nor necessary.

Then there are the eyes. Whilst you may think you maintain eye contact with your patient throughout an appointment I can guarantee that you will take your eyes off them even if it’s only to glance down whilst you write. If you can manage to write neatly without looking down at the paper all credit to you …. but please don’t stare at your patients for too long, it’s creepy! Then there’s the hardware to consider. What do you want to use? Do you use a standard desktop computer, a laptop or a tablet? The truth is that they all have their strengths and weaknesses. I’m a great fan of the traditional desktop which can be the workhorse of a clinic. That way its sole function is for recording clinical information, not for ‘Facebooking’ friends or ordering things from Amazon. Having said that, though, these days web-based software such as TM3, combined with prices for smaller devices falling means that their popularity is on the up. Some clinics I have worked with take advantage of this by letting practitioners use their own computers rather than having the financial outlay themselves as most practitioners have some sort of computer. Don’t worry, though; one of the many benefits of web-based software is that clinical information is never stored on the computer itself, but that’s another article entirely!

It’s a sound idea to plan at the outset what it is exactly that you want out of the system. In effect, you work backwards. Do you want to record PROMS? Do you want to know the types of cases and different diagnosis that you are seeing? Or perhaps you are keen on Clinical audit or a tool for standardised data collection? All of these and much more are possible when using electronic clinical notes, the information you record during your consultation is not dead anymore it’s alive! So I’ll leave you with a final thought …. Imagine the rich information we would all have if every Osteopathic consultation was recorded in this way, now that would be an evidence base!

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