January 21, 2005

Paper chart still vital part of patient care record

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Allan Bass, M.D.

Paper chart still vital part of patient care record

Vanderbilt is taking new measures to ensure the integrity of inpatient charts and is reminding doctors that, while the electronic medical record system has allowed outpatient areas to go mostly paperless, the system isn't yet complete and sufficient for use in the hospital, where the paper chart remains critical for the coordination of patient care.

The Medical Center Board has approved a policy requiring all inpatient documentation to be printed and added to the paper chart. Newly developed electronic medical record features make it easy for doctors to comply.

“While work continues toward a more electronic work environment in the hospital, we needed these few additional measures in the meantime to protect the paper chart used at the bedside,” said Jim N. Jirjis, M.D., assistant chief medical officer, director of the Adult Primary Care Center and chair of the Medical Records Committee.

All signed, dictated notes are automatically forwarded to Medical Records for potential inclusion in the paper chart, but when users bypass dictation and enter notes directly into the system it's left to each user to decide whether to print and file the information. Jirjis said it has become more efficient for doctors to skip dictation and enter notes themselves, and this has inadvertently raised opportunities for holes to occur in the bedside paper chart.

To make it easy for doctors to comply with the new policy, three of the system features they use to enter patient care documentation — StarNotes, “Type New Document,” and “Attending Attestation” — all now give the option of clicking to send an inpatient note to Medical Records for filing in the chart. Doctors who prefer to print and place inpatient notes in the chart themselves are welcome to continue doing that, Jirjis said.

For a short presentation about the new electronic medical records feature, turn your Web browser to http://sss.mc.vanderbilt.edu/Jirjis-Inpatient-Notes.ppt.