General Comparison of Systems


System Advantages Disadvantages
Handwritten charts

Cheap - essentially no cost up front

Quick (the more incomplete, the quicker they are)

High risk of inadequate doumentation
  • Lower quality of care
  • Increased malpractice exposure
  • Lower reimbursement

Slow charting (if done properly)- poor physician productivity

Often illegible and leads to:
  • Poor medical staff relations
  • High risk of poor continuity of care
  • Slopping appearing charts
  • Poor risk management>
  • JCAHO citations for illegibility
Dictation

Very legible

Medical staff loves them

JCAHO preference

EMR compatibility - text can be searched improving QI integration

 

High cost

Often unavailable

Requires transcription

  • Delaying availability
  • Potential for poor continuity of care
  • Potential risk management issues

Very slow - poor productivity

  • High risk of inadequate documentation

Requires quiet area to dictate

Any bedside work (notes) must be redone

Templates

Variable costs - some are low

Substantial increased productivity

Rapid attention to billing requirements

Can incorporate risk management coaching

Can incorporate QI adherence directives

Variable cost - some present significant cost considerations

Often poorly accepted by medical staff
  • Cluttered appearance makes key info hard to see

Can present a steep learning curve. The higher the number of templates and the more cluttered the template, the worse the problem.

Often offer little ability to indivdualize chart to address specific needs of a patient or case

The greater the number of templates, the greater chance of using the wrong one (they are selected before the encounter).

Unexpectedly high complexity visits may be undercoded as template not designed to capture the higher level of required elements. Lost revenue.

Unexpectedly high complexity visits may be undercoded as template not designed to capture the higher level of required elements. Lost revenue.


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