Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians

Abstract

Clinical documentation was developed to track a patient's condition and communicate the author's actions and thoughts to other members of the care team. Over time, other stakeholders have placed additional requirements on the clinical documentation process for purposes other than direct care of the patient. More recently, new information technologies, such as electronic health record (EHR) systems, have led to further changes in the clinical documentation process. Although computers and EHRs can facilitate and even improve clinical documentation, their use can also add complexities; new challenges; and, in the eyes of some, an increase in inappropriate or even fraudulent documentation. At the same time, many physicians and other health care professionals have argued that the quality of the systems being used for clinical documentation is inadequate. The Medical Informatics Committee of the American College of Physicians has undertaken this review of clinical documentation in an effort to clarify the broad range of complex and interrelated issues surrounding clinical documentation and to suggest a path forward such that care and clinical documentation in the 21st century best serve the needs of patients and families.

Clinical Data Reuse or Secondary Use: Current Status and Potential Future Progress

“…However, measures to progressively improve and increase secondary usage of clinical data, from billing to quality assessment or from clinical research to public health, have increased purposes beyond the direct care of the patient. This has led to an important increased workload for care professionals [187]. Clinical documentation requires 25-50% of clinicians' time and, in a recent narrative review by Clynch and Kellett, there has been almost no formal research to assess its value, or on whether the time spent on it has negative effects on patient care [188].…”

Sharing notes with patients

“…Finding this balance remains a challenge for providers. 6 CONCLUSION Releasing notes to patients can be done in varying ways, and should be considered as a potential way to improve and increase patient engagement as well as potentially improve quality of care. Neurologists should consider the 5 Ws when planning a note release program: why, who, what, when, and where.…”

“…6 Although concern may exist that electronically sharing notes with patients may result in watered down notes, one should always write medical notes for their primary purpose while keeping in mind that they may be read by anyone with a right to access the chart, including patients, administrators, auditors, billers, lawyers, and researchers.…”

“…While these tools have been criticized for contributing to notes that stray from their primary clinical patient-centered purpose, increased transparency associated with shared notes may encourage improved documentation including "avoidance of pejorative language.and increased clarity in.care plans." 6 Guidelines and reviews for specific conditions may offer neurology-specific recommendations on documentation but rarely on sharing this documentation with patients.…”

Medical Scribes: Salvation for Primary Care or Workaround for Poor EMR Usability?

“…While the burden of clinical documentation is only one of a number of stresses currently facing primary care clinicians, listening to concerns in the literature and hallways, it may well be the straw that is breaking the camel's back, with reports of clinicians spending two to three extra hours each night writing notes instead of spending time with their families. 2 Thus, the prospect of having a personal scribe take care of the charting and thereby allow us to spend more time better interacting with our patients as well as finish our work in a more timely way, is irresistible. As a result, medical scribes, medical scribe vendors, and practices adopting this model are rapidly proliferating, and an estimated one in five practices with an electronic medical record (EMR) currently use scribes.…”