There are several pros and cons of the many documentation techniques for an EHR. Below, you will see the advantages and disadvantages of the different EHR documentation methods. This will give you an idea of which one, or combination, would be best for use at your clinic.

Structured Templates

There are several benefits of using structured templates including ease of note taking. The doctor is presented with a draft that he or she can then change or modify to reflect the patients current condition.

There are other “pop-ups” that may occur while filling out a structured template. If the patient complains about chest pains, a pop-up with questions about daily exertion, the family history, and if the patient smokes would appear. These templates also allow clinics to create not only medical records but also structured data that can direct functions such as medical alerts and even treatment suggestions.

The disadvantage of structured templates is that when used alone, they can be a difficult to read as a whole story. Templates make individual health narratives very difficult to piece to together. Some templates are profiled, leaving symptoms as negative unless the doctor specifically checks positive.

This may seem like it is giving information that the doctor really did not record. Making it seem as if the doctor asked the question, and checked negative when that simply is not the case. Misreading and misinformation is a big drawback of the structured template.

Radio Buttons and Checklists

This method permits a quick input of the patients’ records. These can be especially useful when combined with EHR. This advantage is simple but excellent.

The disadvantages of the system is the back and forth repetition. The health care providers themselves have complained about shifting from keypad to mouse over and over again. Some have even complained about the spacing between checklists. There is a small amount of concern that the lists are too close, causing the wrong boxes to be checked.

Manual Entry

This is the oldest form of transcription and is the most reliable. It is also the most time-consuming way to record clinical data. If the typist is fast and efficient, then this could be an excellent way to make sure all your records are transcribed.

The disadvantage of manual entry is that the papers are not coded or linked. That means they are not able to ask for additional information.

Speech Recognition

The advantage of speech recognition is clear; there is no faster way than to simply speak the form out. It will provide the most detail on an individual patient quickly and with little effort needed.

The disadvantages of speech recognition include not being coded or linked, just like manual entry. Another problem is clear understanding of the doctor’s terms and words. SR technology needs to be adapted to the doctor’s vocabulary, speech patterns, and accent.

After reviewing these pros and cons of all the documentation techniques for EHRs, it may take a little thinking to know which is best for your clinic. When considering the possibilities, remember, most clinics do not use a single method but a combination of the choices.