Electronic Health Records

How I Practice Video Series
Peter C. Manning, MD, FACOG

HIP: Electronic Health Records from ACOG on Vimeo.

Transcript:

Transitioning to an electronic medical record is not easy. One of the challenges is taking notes in room with a patient and making the patient feel engaged and listened to. Many patients come away from visits feeling like the doctor paid more attention to the computer than they did to them. So there’s a couple of tips that I’d like to share that I have gathered over the last few years practicing with an electronic medical record. Number one: when I first come into a room with a patient, I set my computer aside. I put it on the counter, I look at the patient, introduce myself, and make small talk for a minute or two to make the patient feel like I’m really focused on them. Then I’ll let the patient know that I’m going to get logged in to the computer and take some notes as we’re talking. And at that point the patient knows that I’m going to focus on the computer for a minute. When I’m ready, I’ll ask the patient to explain what’s going on and I’ll take my notes. And I find it most helpful to type at a speed where I can maintain eye contact with the patient. If I make a spelling error or a typo, I just leave it there and keep going. And then while the patient’s getting changed for the exam or after the encounter, I’ll fill in the details. I’ve also found it helpful to use an embedded dictation system. This allows me to get more detail into my note than I would if I was typing because it tends to be quicker. At follow up visits, it’s easier to remember what was happening with the patient and it improves the quality of the notes that you send back to a referring physician. Sometimes during the discussion with the patient, a sensitive issue will come up and I’ll put my computer aside completely. And that gives a little better connection between me and the patient and I’ll type in the details afterwards. At the end of the visit, I’ll close the same way. Put the computer aside, make eye contact with the patient, and I always like to specify the follow-up and the plan with the patient after I’ve set aside the computer. And then I’ll walk the patient out to check-out. And that’s how I practice.

   

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