Streamlining documentation in patient electronic medical records: An example of chlamydia consultation shortcuts.

Abstract

Background: Australian general practitioners encounter a vast array of health issues in their clinical practice. High-quality clinical record keeping is crucial to support continuity of care for patients and decision making for clinicians. Many clinical software programs used in general practice contain shortcut features that allow insertion of pre-stored, editable text into progress notes. These can be used to support documentation of specific health issues.

Objective: Drawing on our experience within a research project seeking to strengthen chlamydia management in general practice, this article describes the co-design, implementation and use of documentation shortcuts for chlamydia management.

Discussion: Shortcuts are useful as a memory prompt and timesaver for general practice clinicians. It is important that they do not replace clinical acumen and judgement. General practices using our chlamydia management shortcuts found them easy to set up, that they acted as a prompt for best practice chlamydia management and that they integrated well with the general practice workflow.