The Electronic Health Record and the Clinical Examination.

Hedian, Helene F; Greene, Jeremy A; Niessen, Timothy M · Med Clin North Am · 2018

review · Level V

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Abstract

This review examines how the adoption of the electronic health record (EHR) has changed the most fundamental unit of medicine: the clinical examination. The impact of the EHR on the clinical history, physical examination, documentation, and the doctor-patient relationship is described. The EHR now has a dominant role in clinical care and will be a central factor in clinical work of the future. Conversation needs to be shifted toward defining best practices with current EHRs inside and outside of the examination room.

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