Chapter 22: Medical Documentation

INTRODUCTION

Medical documentation can edify and enhance patient care, but note writing intimidates many clinicians, both learners and seasoned practitioners alike. Our aim here is to help clarify the rationale for note writing and underscore some best practices to help master the art of effective, efficient documentation.

BRIEF HISTORICAL PERSPECTIVE

The written medical record in Western medicine dates to the time of Hippocrates and initially consisted of anecdotal case histories recorded largely for didactic use. In the 4000 years since its inception, written clinical documentation has evolved significantly, shifting from an occasionally used educational tool to a broadly adapted instrument informing real-time care of individual patients.

While widespread propagation of written medical records improved patient outcomes, clinical notes remained handwritten for most of the 20th century, which left the challenge of deciphering illegible handwriting and difficulty sharing information among providers in different healthcare settings. While doctors, as a group, do not actually have worse handwriting than the population at large, up to 15% of handwritten notes have been found to be illegible, which can have outsized consequences on patient care.

Starting in the 1990s, with the rise of personal computers, electronic medical records (EMRs) began to propagate. Fueled in part by funding from the 2010 Affordable Care Act, EMRs had a meteoric rise, with documented use in 9% of hospitals in 2008, increasing to 96% by 2015. The EMR eliminated the perils of handwritten notes but opened the door to a new set of challenges.

CHALLENGES OF THE EMR

While patient care has benefitted from the development of standardized clinical documentation, negativity surrounds electronic note writing, stemming largely from the volume of time it absorbs. As Thoreau said, “Men have become the tools of their tools.” Some challenges are as follows:

Clinical Time Is a Zero-Sum Game

• More time writing notes equals less time spent with patients.

• More than 65% of medicine residents reported spending >4 hours/day working on documentation, whereas <30% reported spending >4 hours/day on direct patient care.

• Clinicians are demoralized to find note writing time supplanting meaningful bedside time, a phenomenon Verghese describes as the “iPatient.”

Attempts to Improve Electronic Note Writing Efficiency Can Backfire

• Copy-and-paste is a method of expediting note production, but leads to:

  • Note bloat

    • A snowballing effect wherein notes become haphazardly bloated with disorganized, internally inconsistent, pasted information.

    • Median note length increased by 60% from 2009 to 2018 with a significant increase in note redundancy.

  • Chart lore

    • Inaccurate data carried forward from note-to-note without verification.

• Consequences of electronic copy-and-paste Frankensteinian notes:

  • Worsened patient outcomes

  • Provider burnout and disengagement

Our goal in the remainder of this chapter is to outline a practical approach to electronic note writing that will improve the experience for both reader ...