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Association of Medical Directors of Information Systems Consensus on Inpatient Electronic Health Record Documentation

Journal: Applied Clinical Informatics
ISSN: 1869-0327
DOI: https://doi.org/10.4338/ACI-2013-02-R-0012
Issue: Vol. 4: Issue 2 2013
Pages: 293-303

Association of Medical Directors of Information Systems Consensus on Inpatient Electronic Health Record Documentation

Review

J. Shoolin (1), L. Ozeran (2), C. Hamann (3), W. Bria II (4)

(1) Advocate Healthcare, Glencoe, Illinois, United States; (2) Clinical Informatics, Inc., Yuba City, California, United States; (3) Accenture LLP, Health/Clinical Services, Boston, Massachusetts, United States; (4) AMDIS, President, Saint Petersburg, Florida, United States

Keywords

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

Summary

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.

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