Electronic Health Records

SIU School of Medicine, Springfield Memorial and HSHS St. John’s Hospital work together in a three way partnership to provide your residency education. However, because they are three distinct institutions, each partner has its own electronic health record. In the long-term, being fluent in multiple EHR systems is actually an advantage; in the short term, it means your learning curve will include learning three new systems. The systems and contact numbers for assistance are: 

It is tempting to think of progress notes and other clinical documentation as “busy work” or “service”. This is inaccurate. Written communication of your findings, plan and reasoning process is a vital part of patient care. During your training at SIU and your career, you will utilize multiple different EHRs. An EHR can provide efficiency in documentation, but they must be used correctly and with caution.

Important things to remember when working in EHR

  1. Be sure you are in the correct patient's record.
  2. Timely, accurate and honest reporting of information. Most EHRs allow you to pull your note from the previous encounter and "cut and paste". Be very careful with this function. It is easy to forward information that is no longer valid.
  3. Diagnostic thinking and assessment plan. Please keep in mind that is likely the first, and often only, section others will read in your note.
  4. Over documentation. Including information that does not pertain to the visit/encounter is a liability and creates a lengthy note.
  5. Confirmation of accurate information. With each visit/encounter, confirm that the information in all areas of the note is up to date so that no inappropriate or incorrect history gets perpetuated from one visit to the next.
  6. Completeness of note. Do not forget to complete all important sections.
  7. Summary of diagnostic data. It is important to remember to consolidate the summary of a report into a note in a meaningful way. 
  8. Transparency. Multiple people will read your notes. Each individual needs to be able to easily interpret the course of care for the patient through clear concise documentation.
  9. Special areas of concern:
    1. On any given progress note, only include history and exam findings you have actually performed. 
    2. Pay particular attention to drug interactions and allergies provided by the system. (i.e. Active Problem List, Past Medical History, Past Surgical History, Allergies and Medications)
    3. Always pay attention to EHR alerts regarding interactions between drugs. (i.e. Allergies, Drug to Drug interactions and Dose Alerts)
    4. Double check the number of pills and refills when placing EHR prescriptions.
    5. Checkbox lists make it easy to accidentally click the wrong order. Double check before you place the order.
    6. The chart notes you produce are professional documents and should look professional.
    7. Ensure you are sending your notes for cosign / endorsement to your attending for them to sign. If you work for multiple attendings during a rotation, only send to the ONE attending to cosign that is on with you for that date.
    8. Please use appropriate attestation statements for scripts, medical students and residents when applicable.
  10. Your program coordinator may have additional resources for efficient processes.