Posted: Sat Dec 31, 2005 6:26 am Post subject: non EMR medical progress notes
I am a physician that cares for house-bound elderly patients. I have run my home care practice using standard paper charts that I keep in a big bin in the trunk of my car. It all seems so arcane, so last week I bought a tablet pc...
As for an EMR, my needs are very simple. I do not have a large volume of patients, I work alone, I have to input everything myself as I do not make house calls with an assistant, and I cannot use a web based EMR- it all has to be saved in the tablet.
My house call charts need a face sheet with demographics, problem lists and meds (the cummulative patient profile or CPP), and a section for progress notes.
I would prefer to use standard MS Office programs because my needs are simple and I never have to worry about recovering data from a defunct vendor's custom EMR program.
One simple solution would be to have one folder per patient and keep an Excel file for the CPP and the progress notes in Journal (saved as digital ink).
Another more elegant solution would be to use OneNote with each patient having its own tab and then using different subtabs for the CPP, progress notes, scans of letters and lab reports etc.
How does this sound? What other non EMR solutions have people used?
Posted: Mon Jan 02, 2006 6:07 am Post subject: tablet based patient chart
A simple OneNote based charting system appears to be almost ideal except that (correct me if I am wrong) you cannot import pdf files into it. Scanning consult letters, reports, previous paper based progress notes, x-ray and lab results into each patient's file is an essential requirement for my needs. I suppose I could have a separate folder for each patient each containing a separate OneNote folder as well as a place to put pdf scans of reports etc.
Or I am left with the option a folder for each patient containing an Excel sreadsheet (for demographics, problem lists, medications etc.), a Journal file for progress notes (mostly hand written digital ink), and pdf files for scanned reports etc. My EMR can really be this simple.
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