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.
Citation: Shoolin J, Ozeran L, Hamann C, Bria W. II. Association of Medical Directors of Information
Systems Consensus on Inpatient Electronic Health Record Documentation. Appl Clin Inf
2013; 4: 293–303
http://dx.doi.org/10.4338/ACI-2013-02-R-0012
Keywords
Clinical documentation - inpatient clinical notes - documentation process - information
capture - SOAP - APSO note - copy-paste - note bloat
