By Kuhn T, Basch P, Barr M, Yackel T, et al.
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.
In the past decade, medical records have become increasingly synonymous with electronic health records (EHRs). However, although “EHR” is the current term of art used to describe computer-based systems that perform a broad range of functions related to documenting and managing patient care, this will not always be the case. Similarly, clinical documentation’s definition has grown to encompass more than just physician notes. Existing technology, such as registries, portals, connected home monitoring devices, and provider- and patient-controlled mobile devices, as well as technology not yet in use or even built, is likely to integrate with or possibly even replace the EHR (as currently conceptualized) as a primary vehicle for viewing and recording clinical documentation. Although the term “EHR” is used throughout this paper, the issues addressed could reasonably apply to any future technology-enabled system of clinical documentation.
This position paper reviews the current and emerging purposes of clinical documentation, the drivers that may influence or distract from these purposes, and the opportunities and challenges that have arisen from EHRs. We believe that physicians must help define and prioritize the many important roles that clinical documentation serves today. Therefore, this paper proposes a set of guiding principles and actions that can be taken by clinicians, provider institutions, technology vendors, government regulators, payers, and other interested groups to improve the quality and value of clinical documentation and to better use this documentation to improve care.
The primary goal of EHR-generated documentation should be concise, history-rich notes that reflect the information gathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up. Technology should facilitate attainment of these goals in the most efficient manner possible without losing the humanistic elements of the record that support ongoing relationships between patients and their physicians.
Kuhn T, Basch P, Barr M, Yackel T, for the Medical Informatics Committee of the American College of Physicians. Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians. Ann Intern Med. 2015;162:301-303. doi:10.7326/M14-2128