I am a plastic surgeon, looking at OpenEMR to replace paper charts in my office. One question that has come up involves use of a nurse or other person acting as chaperone during breast exams. Following the advice of our malpractice insurance carrier, as soon as the visit concludes, the nurse stamps the (paper) chart “Chaperone present during exam”, then signs, dates, and times the entry. Later, when the transcription is available, it is attached just under the stamp. How would this documentation step be carried out under OpenEMR? Would the nurse make her own chart entry for the same date and time?
I think the right way to do this is going to vary depending on your overall workflow and things like, is there one computer in each examining room? or is there a computer assigned to each practitioner that they keep with them? There is certainly no “best practices” approach for this yet.
One approach would be to create a clinical form for Chaperoning that the escort would fill out that would be associated with the overall encounter. This would be similar to how a nurse could fill out the vital signs form separately from the physicians documentation. I think this what you were thinking which is a reasonable strategy. However, if the deployment of computers is such that there is one in the exam room, at what point does the nurse use the computer to document the chaperoning if the physician is using the computer? Also, what if the escort isn’t someone who routinely uses the clinical system?
Also, the question of how best to"sign" a document in OpenEMR is still an issue that we haven’t fully addressed as a community.