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Documentation


Document, document, document!

Electronic medical records


Electronic medical records (EMRs) offer real advantages in accessing the health information of your patients.

Medical students should:

  • Spend some time to learn how to use the software.
  • Give the same attention to documenting patient care in an EMR as when using a paper medical record.
  • Be aware of any specific College, hospital, clinic, or office rules about documenting patient care, and making additions, edits, and corrections to medical records.
  • Never disable the software's audit capability with the intent to improve system performance, change information, or for any other purpose.

Decision support tools and alerts

Many EMRs include tools to help with decision-making and to alert users to potential problems such as drug interactions.

These tools should never be disabled. The information should be considered to determine if it is relevant for your patient.

When using such tools, it is vital to write a clear note in the record that indicates the thought process leading to the reason for having chosen an alternative treatment.