Documenting care and decisions, made with patients and their loved ones, helps ensure that all members of the patient’s health care team are able to provide the most appropriate health care.

IHealth will improve patient safety and care by reducing errors, supporting better care coordination, improving care transitions and facilitating individualized patient health and care planning.

Many of the benefits of the electronic health record (EHR) rely on real-time documentation. One such benefit is the ability to see other clinician’s assessment documentation in real time. Also, based on that assessment documentation, the EHR will alert clinicians of potentially negative situations in patients (e.g., sepsis or VTE).

Although documenting in real time may be a significant challenge in your care setting, standardized documentation and documentation practices are the cornerstones of health care – without them, the EHR will not give a timely, accurate or complete picture of the patient.
For more information about documenting with the new EHR, check out these FAQs: