The Electronic Health Record and the Clinical Examination

Helene F Hedian; Jeremy A Greene; Timothy M Niessen

doi:10.1016/j.mcna.2017.12.009

The Electronic Health Record and the Clinical Examination

Med Clin North Am. 2018 May;102(3):475-483. doi: 10.1016/j.mcna.2017.12.009.

Authors

Helene F Hedian¹, Jeremy A Greene², Timothy M Niessen³

Affiliations

¹ Division of General Internal Medicine, Johns Hopkins University School of Medicine, 10753 Falls Road, Suite 325, Lutherville, MD 21093, USA. Electronic address: [email protected].
² Department of Medicine, Johns Hopkins University School of Medicine, 1900 East Monument Street, Welch 324, Baltimore, MD 21205, USA; Department of the History of Medicine, Johns Hopkins University School of Medicine, 1900 East Monument Street, Welch 324, Baltimore, MD 21205, USA.
³ Division of General Internal Medicine, Hospitalist Program, Johns Hopkins University School of Medicine, Meyer 8-134-H, 600 North Wolfe Street, Baltimore, MD 21287, USA.

PMID: 29650069
DOI: 10.1016/j.mcna.2017.12.009

Abstract

This review examines how the adoption of the electronic health record (EHR) has changed the most fundamental unit of medicine: the clinical examination. The impact of the EHR on the clinical history, physical examination, documentation, and the doctor-patient relationship is described. The EHR now has a dominant role in clinical care and will be a central factor in clinical work of the future. Conversation needs to be shifted toward defining best practices with current EHRs inside and outside of the examination room.

Keywords: Clinical examination; Doctor-patient relationship; EHR; Electronic health record; History; Physical examination.

Publication types

Review

MeSH terms

Communication
Documentation
Electronic Health Records*
Humans
Medical History Taking / methods
Physical Examination* / methods
Physician-Patient Relations*