You are a general otolaryngologist in a large suburban community, a partner in a three-otolaryngologist practice. Over the past 10 years, your practice has transitioned from paper records to an electronic health record (EHR) system, which now includes the scanned paper records from the past.
Explore this issue:April 2016
Transition to EHR was difficult in the busy practice, but now you and the other otolaryngologists and your staff are utilizing it efficiently. At first, however, you employed a scribe to assist you in data management, which was such a help that you
continue to use a scribe even though the transition to EHR is complete. While you interact with the patient and perform the physical examination, the scribe enters the data elicited—including present illness, past medical history, and physical examination findings. From time to time, you indicate certain information that needs to be input in a particular manner, including diagnosis, treatment plan, and medications to be prescribed. It has been your practice to review the data immediately after the patient leaves the examination room for accuracy and completeness, making your own revisions as indicated, and electronically signing the encounter. The scribe utilizes your password to sign into the system each day.