Electronic medical record customization and the impact upon chart completion rates.

Abstract

OBJECTIVE: The study's objective was to determine if alterations to the utility of an existing electronic medical record (EMR) application resulted in an improvement in clinical operations. METHODS: We altered several templates within an existing EMR application to improve ease of documentation of clinical encounters. These changes were disease specific, brought documentation into central locations, and altered the input method to facilitate point of care documentation. We examined the length of time (in days) from the creation of a chart entry to the final signing of that chart entry. These charts were delimited to faculty providers who had an active clinical practice during the entire study period. RESULTS: We discovered that the template changes resulted in an increase in the number of charts completed within 30 days by nearly 5%, resulting in a substantial number of billable clinical encounters. CONCLUSIONS: This improvement is important, as compliance policies prohibit the billing of encounters if the chart is not completed within 30 days. We conclude that simple, inexpensive changes in existing technology may be adequate to have a significant impact upon an organization.