Over the past year, Western Psychiatric Institute and Clinic (WPIC) physicians have been entering clinical documentation into the psychiatric Ambulatory eRecord (PsychConsult). System enhancements were designed to facilitate physician documentation process within a single unified screen. The project incorporated the input of more than 20 WPIC physicians in the development.

Physicians participated in design sessions, prototype review, content development, implementation planning, and project leadership. The new documentation process provides more timely access to medication history, diagnosis, and other clinical documentation.
Physician documentation of patient identifying information, mental status exam, and patient education was streamlined, eliminating the need for traditional dictation and transcription.
As soon as the changes were completed, same day documentation completion by WPIC physicians rose from 39% to 73% for all 4,000 monthly WPIC medication management service appointments. This represented an 85% improvement, which has remained consistent throughout the year. This change also allowed for an estimated $250,000 in savings through reduction in transcription costs, speedier charge capture and has been
found to improve the quality of the documents.