Improving documentation in Epic for Pediatric Hematology-Oncology Patients
Project Description: Keeping good medical records is important for providing good care and for facilitating communication among different care providers. Medical care is provided by medical teams rather than individuals and it is important that information is kept in a systematic way so that any member of any team can easily and quickly find accurate and relevant information. If used as designed, Epic system has made it easier to maintain uniform medical records as it has pre-defined fields for medical history, social history, medications, etc. Epic system supports problem-based (as opposed to system based) documentation; however, in order to be accurate, chart requires maintenance. Inactive problems can be easily moved to medical or surgical history, while a few active problems require updates. Once components of the chart are updated (history, medications, problem overviews) a new note can be generated by assembling the above components. If problem overviews are maintained, detailed information about active problems can be easily identified. The goal of this project is to improve documentation in Epic by filling properly components of medical records including past medical history, family and social history and documenting history of active problems in the problem overview section.
QPI: Biljana, Horn, (email@example.com)
UF Health Big Aims:
MeSH Keywords: electronic medical record, medical record, none