Going Paperless Part 2
September 27, 2011
In part 1, I talked about the benefits of paper charts and what they represent. They represent the heart of the patient’s experience in our office and a permanent record of the care we have given them. With the shredding of these charts and our movement into electronic systems, that feeling of permanence and well established written record is not the same at this point. I know it is a new experience for us and my opinion may change about this. I have been working with these electronic charts now for about a week and it is a struggle to properly document and make permanent all the aspects of the patient’s medical condition and my thoughts about where we need to go of the treatment. That is one of the most difficult aspects of this whole experience. The care for our patients and this includes my staff, is always paramount in our mind. We talk to the patient and respond to what they say. The whole purpose of the charts, as we have discovered, is to make a record of our interactions with these patient so that we can refer to them later. It is also a record of the patient as it will be published to the whole world. The new patient exam is entered into the computer in the form of SOAP notes, which stands for subjective symptoms, objective symptoms, assessment, and plan. This initial exam is organized and typed into the computer and printed out in a format, which all the referring doctors, insurance companies, and the patients and any body else in the future, would see as what we determine as their concern and the treatment plan from this point forward. In order to make this an efficient process with the EMR, of course, one has to anticipate what the patient is going to say and put them into drop down boxes so that the assistant can choose the correct responses and then will automatically go into this document. That has taken a month to formulate and I believe it will take me several more months to eventually get it to the point where this system will be efficient.
Ronald S. Prehn, D.D.S.
Diplomate of the American Board of Orofacial Pain
Diplomate of the American Board of Dental Sleep Medicine
