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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 VoiceTyping
Dictation
.probl : brings up problem
list with comments
.cmed : current medications
NEXT?

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Amdis documentation panel shoolin

  • 1. The Future of Clinical Documentation AMDIS Panel 2013 Annual Physician-Computer Connection Symposium June 27, 2013 Facilitator: Joel S. Shoolin, DO
  • 2. ∗Panelists ∗ Claus Hamann, MD (Accenture) ∗ Nick vanTerheyden, MD (Nuance) ∗ Tom Ormondroyd (Precyse) ∗ Jonathan Handler, MD (M*Modal) AMDIS Documentation Panel
  • 3. After a lot of hard work, "American Medical Directors of Information Systems Consensus on Inpatient Electronic Health Record Documentation“ is published! AMDIS Documentation Panel
  • 4. 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
  • 5. What is documentation’s future ? AMDIS Documentation Panel
  • 6. The history and future of documentation AMDIS Documentation Panel Paper SmartText VoiceTyping Dictation .probl : brings up problem list with comments .cmed : current medications NEXT?