Data Entry at the Point of Care

A healthcare professional spends a great deal of time during a patient encounter on documentation. The clinician must document the patient's symptoms, medical history, physician orders, observations, assessments, and all other aspects of the patient care. Documentation is extremely important for quality care and the health record must be accurate. Accuracy is improved when the clinician enters the data during the patient visit rather than later after the patient has left the facility. This is called point of care or real time data entry in the EHR.

The features of the electronic health record help to improve the efficiency of documentation. The EHR has numerous features that can tremendously save time for the clinicians in completing the required documentation.

After completing this resource, learners will be able to:

• Use Forms
• Use Review of Systems Load and use
• Lists of Findings to speed up data entry