NextGen EHR Dermatology chart abstraction

When switching from paper charts to a Electronic Health Record (EHR) you have to decide what, if anything, will be transferred into the EHR.

There are three main points to think about. 1.) What information is most important to have in the EHR. 2.) How to input the information (scanned images or field input). 3.) The order and timing of chart abstraction.

Only you can decide what is important to abstract, but typically at minimum you would want allergies, medications, and history of disease. The NextGen chart abstraction template has the things that NextGen feels is most important.

I didn’t entirely agree with their choices, and I also thought a form that matches our history questionnaire form would decrease the time it would take for each chart abstraction. This is an important point. Taking a little bit of time and expense to modify the chart abstraction template is going to give you better data that you are going to be relying on for years to come, and creating a chart abstraction template that allows you to more quickly input data is going to save you a lot of time and expense (in labor) on a greater order of magnitude. You are going to be using this form thousands of times, so increasing the efficiency by a few minutes on each abstraction is going to be a huge time/expense saver.

Some practices decide that scanning their charts and having dozens of files input into each patient record is how they will do their abstraction. This way the provider will have the entire chart available, however not in a very valuable way.

The other way is to take the most important parts of the chart and enter them into the appropriate fields in the EHR. This makes the data valuable and part of the record that will always be visible. This is more time consuming up front, but the information will be utilized better and for a longer period of time.

The last point is to decide whether to start alphabetically with the A’s and just abstract every chart, or to only abstract those charts of patients that are scheduled. Every time a patient is scheduled for an appointment that chart is pulled and abstracted.