Table 1 Charting systems characteristics
Charting system | EMR Features | Method of entry of visit diagnoses* |
|---|---|---|
Paper | ---- | Paper form sent to a processing center, entered by clerk |
Basic | Results viewing (labs), demographics | Basic interface, usually by clerks at the point of care working off of a paper form completed by the provider. Infrequently used method |
Intermediate | Documentation, results viewing, medication ordering, referrals | Electronic version of the paper form, or a search bar within the EMR, entry by providers |
Advanced | Documentation, radiology, laboratory, and medication ordering, results viewing, clinical decision support | Provider chooses ICD9-based diagnoses to create progress note for visit. These diagnoses are communicated to the electronic database after the provider completes chart |