Documenting by exception
OB/GYN documentation
DigiChart improves efficiency through the concept of “documenting by exception,” which means that only deviations from the norm need to be explicitly documented. Providers can mark all findings as normal with a single action, and only make notes on abnormal findings. This approach significantly reduces the time spent on documentation, allowing providers to focus more on patient care.
Documenting by exception saves time by allowing providers to use a single action to confirm all normal findings, rather than documenting each normal finding individually. This method minimizes repetitive data entry and speeds up the overall documentation process, freeing up more time for direct patient care.
Providers can review and adjust the pre-populated data before finalizing the record. This ensures that all entries are accurate and reflective of the patient’s actual condition. The ability to easily document exceptions also means that any abnormal findings are clearly highlighted and addressed.
Benefit of pre-populated normal findings
- Speed and Efficiency: It reduces the time required to document each visit, as normal findings are automatically populated.
- Consistency: Ensures that all normal findings are consistently documented according to the standards set by the American College of Obstetrics and Gynecology (ACOG).
- Focus on Abnormalities: Allows providers to concentrate on documenting and addressing abnormal findings, improving the quality of care.
Testimonials
