Easiest way to carry-forward clinical notes


(Colin MacKenzie) #1

Can anyone tell me the easiest way to carry-forward a previously made clinical note when creating a new patient encounter? IOW’s, what is easiest way to copy the most recent prior note into a current note? It seems time consuming to have to re-create each section of a note with the typical contents specific to each patient each time when all that information was already created at the time of the previous visit.

Alternatively, does anyone have any recommendations for attachable software to do the same?

Thank you
CNM


( htuck@mi-squared.com) #2

Hi Colin-
Not sure about your clinical situation but one of the major safety design factors for EMRs purposely makes it difficult to do precisely what you ask. Being able to carry forward entries with minimal effort makes it far too easy to be superficial and careless in a provider’s care documentation, to say nothing of generating and perpetuating actual errors.
Ideally each clinical note is a uniquely composed entry, and the EMR usually is designed to encourage this. If you want to find a way around the safeguards that’s purely up to you.
Best- Harley


(ViSolve) #3

Hello Colin

We had a similar request from one of our customers earlier and it was an important request for them because re-entering all the details for every visit is very time-consuming.

As you have pointed out, there is no feature available in OpenEMR to carry forward data. So we have done customization of OpenEMR to address the same. It was implemented in such a way that for a patient whenever a new encounter form opened - the last saved encounter’s data will be carry forwarded and the doctor can change the data if required.

One can also customize OpenEMR to have a button called “Copy recent Data” in encounter screen- where only on clicking the same recent data of that patient will be copied to the currently opened encounter. This saves more time during the visit.

Thank You
ViSolve-051