Where's the Beef? The Promise and the Reality of Clinical Documentation

Abstract

Physician-generated emergency department clinical documentation (information obtained from clinician observations and summarized decision processes inclusive of all manner of electronic systems capturing, storing, and presenting clinical documentation) serves four purposes: recording of medical care and communication among providers; payment for hospital and physician; legal defense from medical negligence allegations; and symptom/disease surveillance, public health, and research functions. In the consensus development process described by Handler, these objectives were balanced with the consideration of efficiency, often evaluated as physician time and clinical documentation system costs, in recording the information necessary for their accomplishment. The consensus panel session participants and authors recommend that 1) clinical documentation be electronically retrievable; 2) selection and implementation be evidence-based and grounded on valid metrics (research is needed to identify these metrics); 3) the user interface be crafted to promote clinical excellence through high-quality information collection and efficient charting techniques; 4) the priorities for integration of clinical information be standardized and implemented within enterprises and across health and information systems; 5) systems use accepted standards for bidirectional, real-time clinical data exchange, without limiting the location or number of simultaneous users; 6) systems fully utilize existing electronic sources of specific patient information and general medical knowledge; 7) systems automatically and reliably capture appropriate data that support electronic billing for emergency department services; and 8) systems promote bedside documentation and mobile access.

A Qualitative Analysis Evaluating The Purposes And Practices Of Clinical Documentation

“…Second, documentation has multiple purposes that include, but are not limited to, clinical care. Providers and administrators in our focus groups identified four other key purposes of clinical documentation: administrative, legal, and research -consistent with the goals of the medical record identified in previous research [22][23][24][25][26][27][28][29][30][31] -and medical education, previously unreported and perhaps only applicable to academic training facilities. Nonetheless, the multiple purposes of documentation are consistent with providers' belief that the clinical note is a shared record that serves multiple stakeholders.…”

Analysis and classification of oncology activities on the way to workflow based single source documentation in clinical information systems

“…Thus, there is still a considerable gap between clinical patient documentation and supplementary data collection for registries, quality assurance and research. This often results in multiple and overlapping documentation activities on various media [ 1 , 31 , 32 ].…”

Emergency Medicine Quality Improvement and Patient Safety Curriculum

“…On occasion, these statements can be inadvertently included in the medical record. Although EMRs theoretically reduce the cost of documentation via discontinuation of traditional documentation systems (e.g., transcription), their weakness continues to be lost productivity due to the increased time it takes to document an encounter in many, if not most, of the available systems 52,56–59 …”