Integrating Medical Documentation into Provider Order Entry

Introduction: Clinicians currently have complex requirements for the content of their medical documentation. This increases the amount of work and time needed to document clinical encounters. There is a need to develop multi-purpose systems that can simultaneously capture patient information, prompt the clinician to be comprehensive and perform clinical and administrative tasks with the information, all while respecting the time constraints of a busy clinician. The authors have built and integrated a template-driven clinical note capture tool (CNCT) into their institutional computerized provider order entry system (POE). Templates are created using simple markup so that clinicians can rapidly build and maintain their own content. Templates exist for many types of clinical notes, including History and Physicals, Progress Notes, Procedural Notes, Discharge Summaries, and Contractual Agreements, such as consent forms. In 2001, 1184 different users wrote more than 80000 notes. Users included Physicians, Medical Students, Nurse Practitioners, Dieticians and Nurses. This paper describes the technical aspects of the note editor. Methods: The CNCT (Figure) is a pure Java application that is embedded in the institutional POE. The CNCT is launched from the patient selection tool, which provides it user authentication and a unique patient identifier. Once the user selects a template, a note document is instantiated with patient and template snecific information and loaded into the notes editor.