Overview

As a practice moves from paper charts to an electronic health record (EHR) in OP, it is important to determine what content needs to be populated into the EHR. Below, are some points to consider before manually entering data or scanning data into patient charts.

Manual Data Entry into an EHR

• Who will manually enter this data into OP?
• If there is a medical decision-making questions, who will address those as they arise during the data entry process?

Scanning into an EHR 

• All Patient Charts will have the following scanned into the electronic chart in OP:
  • Vaccine Records
  • Growth Charts
    • Determine how far back historical Well Visit data growth points should be manually entered.
  • Problem List
  • Allergy List
  • Medication List
• Other documentation may vary based on several factors: 
  • Well Visits/Sick Visits Considerations
    • Based on patient age, how far back will you scan these visit notes?
    • Patients 0-12 months of age.
      • Newborn History/Discharge Paperwork.
    • Patients 1 year to 10 years of age.
    • Patients over 10 years of age.
    • Diagnosis during the sick visit.
  • Diagnostic Tests Considerations
    • Based on patient age.
    • Date of the diagnostic test.
    • Test conducted.
  • Specialists Letters/Referrals
    • Based on patient age.
    • Date of communication.
    • Type of specialist.
  • ER Visits
    • Based on patient age.
    • Date of visit.
    • Reason for visit.

This document can be used as a practice wide checklist, or as a resource to track scanning progress of each patient chart.  It can to affixed to the front of the patient paper chart, and used as a method of tracking progress as the patient paper chart content is converted or scanned to an electronic format.  

Click here to open and print a PDF copy.