The Future of Clinical Documentation

AMDIS Panel

2013 Annual Physician-Computer Connection Symposium

June 27, 2013

Facilitator: Joel S. Shoolin, DO

∗Panelists ∗ Claus Hamann, MD (Accenture) ∗Nick vanTerheyden, MD (Nuance) ∗ Tom Ormondroyd (Precyse) ∗ Jonathan Handler, MD (M*Modal)

AMDIS Documentation Panel

After a lot of hard work, "American Medical Directors of Information Systems Consensus on Inpatient Electronic Health Record Documentation“

is published!

AMDIS Documentation Panel

Without taking away the thrill of your reading the entire article, some takeaways: ∗ Optimize EHR note functionality ∗ Identify coded diagnoses ∗ Keep privacy top of mind ∗ APSO vs. SOAP

∗ Focus on note quality and avoid excessive details ∗ Limit copy and past

∗ Medical education must model best practice

AMDIS Documentation Panel

What is documentation’s future ?

AMDIS Documentation Panel

The history and future of documentation

AMDIS Documentation Panel

Paper

SmartText Voice Typing

Dictation

.probl : brings up problem list with comments .cmed : current medications

NEXT?