Documenting in Your EHR While Focusing on the Patient

Mott Blair, a Wallace, N.C.-based family physician, doesn’t get distracted by the EHR in the patient exam room. That’s because he keeps it in the hallway, right outside the exam room. He uses an old-fashioned clipboard and paper to take notes during patient visits.

“I do all my work face-to-face with patients. I maintain that eye contact, and I always listen,” he says.

This work flow has been intentional on Blair’s part, since he’s witnessed many physicians “caught up” entering data and not focusing their attention on patients.

His patient’s experience starts with a nurse at the practice capturing their vitals, chief complaint, and current medications and documenting those details in the EHR. On his way to the patient exam room, Blair views the patient’s record and then enters the exam room, where he focuses his attention on the patient in the room.

He has his clipboard with a piece of paper on it to make notes about anything that’s out of the ordinary with his patient. “If things are normal, you don’t have to write them down,” he says. Blair updates the vast majority of his patients’ records in the EHR shortly after their visits.

Towards the end of the visit, Blair asks his patient to get dressed and exits the room to update the patient’s record with details from that day’s visit in the EHR. This enables him to hand the patient their visit summary and any prescriptions when Blair returns to the exam room…

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View all Articles Mentioned by: Melissa Clark, CCS-P, RT