Archive for September 8th, 2009

My hospital isn't fully electronic yet; they use a hybrid system where doctors notes and orders are written on paper, to be scanned into the electronic chart at the end of the patient's stay. Everything else (nurse's notes, labs, radiology results) are electronic. It actually works pretty well, with most of the advantages of an EMR (Electronic Medical Record) without forcing the older doctors to use the computer. That's coming, of course, but it won't be pretty.

But those of us for whom the computer is mother's milk, and whose handwriting is somewhere between chicken scratch and Linear A, we'd rather do it all online. I've been writing my admission notes for a few years with a Microsoft Word template, printing them out and putting them in the chart, with nary a problem. And the medical records department clearly used PDF's for the pages, both the blank order sheets and the preprinted, fill-in-the-blanks "standard orders" since they were available on the hospital intranet. So let's create PDF's with actual editable text boxes and check boxes (these are mockups, but they look right):

physician order sheetgastroenteritis order sheet

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