EMR reaches another major milestone with ClinDoc launch
By Michele Rainford
After a mammoth effort by the Information Services Training Department to prepare all UTMB physicians, residents, nurse providers, physician assistants and faculty for the implementation of the new ClinDoc component of the Epic Electronic Medical Records system, the critical component is now operational. Clinical staff in the inpatient areas of the hospital began documenting in the system on Dec. 4.
Inpatient documentation including the Initial Nursing Admission Assessment and Provider Notes encompassing physician documentation, patient history, physicals, multiple daily reports, operative/surgical reports, discharge summaries and consulting notes are now being completed in the Epic EMR system.
Information on patients that start out in the Emergency Department as well as direct-admit patients is automatically detailed in Epic EMR ClinDoc.
A spring update of the system will include more nursing documentation and information for additional roles, such as dieticians and physical therapists, that also document in patient charts.
The Health Information Management Department is working with Information Services to identify all those that document in the patient chart and the way they document to ensure that a process is in place to help facilitate a smooth transition to the new system for those employees that will start to use the system in April.
Documenting in ClinDoc means all orders and notes are in one complete record for each patient. Completing the Initial Nursing Assessment in Epic ClinDoc ensures that all patient information is transmitted along with the patients as they go through each level of care at UTMB.
The new system offers many benefits including the reduction or elimination of legibility problems and missing progress notes, improved patient safety and improvements in workflow for enhanced continuity of care. Also, information gathered on patients is available when they return to the regular clinics for treatment.
UTMB is more than half-way through its phased implementation of the Epic EMR system going from paper patient records to electronic medical records in all patient care areas.