Electronic Health Record Documentation

Computer-based health record documentation via EHRs has been in existence for 50 years. Over time, as EHR systems became more sophisticated, the way healthcare providers document the treatment and services they render to the patient also dramatically changed. Before EHR adoption, healthcare providers would carry paper-based health records into the patient’s room to reference as they discussed and rendered treatment to the patient. The healthcare provider did not document what occurred until after seeing the patient. Today, EHRs allow point-of-care documentation to take place—the healthcare provider can log into the EHR in the exam or treatment room and document in the patient’s health record during the exam or treatment. This change in the way healthcare documentation is captured has impacted treatment workflow in some of the most meaningful ways. See chapter 11, Health Information Systems, for additional information on the EHR.