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Appl Clin Inform. 2013 Jun 26;4(2):293-303. doi: 10.4338/ACI-2013-02-R-0012. Print 2013.

Association of Medical Directors of Information Systems consensus on inpatient electronic health record documentation.

Author information

1
Advocate Healthcare , Glencoe, Illinois, USA. joel.shoolin@gmail.com

Abstract

In 2013, electronic documentation of clinical care stands at a crossroads. The benefits of creating digital notes are at risk of being overwhelmed by the inclusion of easily importable detail. Providers are the primary authors of encounters with patients. We must document clearly our understanding of patients and our communication with them and our colleagues. We want to document efficiently to meet without exceeding documentation guidelines. We copy and paste documentation, because it not only simplifies the documentation process generally, but also supports meeting coding and regulatory requirements specifically. Since the primary goal of our profession is to spend as much time as possible listening to, understanding and helping patients, clinicians need information technology to make electronic documentation easier, not harder. At the same time, there should be reasonable restrictions on the use of copy and paste to limit the growing challenge of 'note bloat'. We must find the right balance between ease of use and thoughtless documentation. The guiding principles in this document may be used to launch an interdisciplinary dialogue that promotes useful and necessary documentation that best facilitates efficient information capture and effective display.

KEYWORDS:

APSO note; Clinical documentation; SOAP; copy-paste; documentation process; information capture; inpatient clinical notes; note bloat

PMID:
23874365
PMCID:
PMC3716423
DOI:
10.4338/ACI-2013-02-R-0012
[Indexed for MEDLINE]
Free PMC Article

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