Medical Records Workflow
SOAP stands for subjective, objective, assessment, and plan.
It is the format used to document a patient’s visit in an orderly fashion. Subjective corresponds to the information the care provider elicits from the patient during the interview, such as complaints and symptoms.
Objective corresponds to the information the care provider gathers from performing a physical exam.
Assessment is the stage at which the physician reaches a diagnosis.
Plan, also known as plan of care, is the stage at which the care provider prescribes medication or additional tests.
To discuss the different components of an EHR, we will first compare the workflow of a provider seeing a patient while using a paper medical record with the workflow of providers seeing a patient while using an EHR.
Problems With Paper Workflow
. Many people have access to the complete medical chart.
. The size of the chart will increase tremendously after a few visits.
. In a follow-up visit the chart may be incomplete or may not be in the file room due to pending dictation or because the physician is using it to review lab results.
. Most importantly: what was the nurse of physician doing at the time of patient interaction? Writing notes!
Questions We Might Ask
. Could they have recorded this data in a computer?
. Could they have saved time later?
. Could the data be entered by someone other than the person seeing the patient?
. Could the patient have completed the information regarding the visit before the visit?
. Are there any instruments that can transfer measurements in a computer system?
. Are there chances for errors in manually writing data in the notes/forms? . Would the time spent entering the prescriptions on a computer justify the benefits of electronic prescribing?
All the problems mentioned earlier are no longer applicable in an office with an EHR system. Obviously, the EHR workflow described is very optimistic. However, it is not far from the truth. As EHR adoption increases, such features and more will improve workflow and quality of care.
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