Clinical documentation in the 21st century

Executive summary of a policy position paper from the American College of Physicians

Thomson Kuhn, Peter Basch, Michael Barr, Thomas Yackel, Mitchell Adler, Robert Brahan, James Cimino, Robert Dolin, Floyd Eisenberg, Jim Jirjis, Nareesa Mohammed-Rajput, Debra Stottlemyer, Alan Wynn

Research output: Contribution to journalArticle

82 Citations (Scopus)

Abstract

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.

Original languageEnglish (US)
Pages (from-to)301-303
Number of pages3
JournalAnnals of Internal Medicine
Volume162
Issue number4
DOIs
StatePublished - Feb 17 2015

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Documentation
Physicians
Medical Informatics
Electronic Health Records
Patient Care
Technology
Delivery of Health Care

ASJC Scopus subject areas

  • Internal Medicine
  • Medicine(all)

Cite this

Clinical documentation in the 21st century : Executive summary of a policy position paper from the American College of Physicians. / Kuhn, Thomson; Basch, Peter; Barr, Michael; Yackel, Thomas; Adler, Mitchell; Brahan, Robert; Cimino, James; Dolin, Robert; Eisenberg, Floyd; Jirjis, Jim; Mohammed-Rajput, Nareesa; Stottlemyer, Debra; Wynn, Alan.

In: Annals of Internal Medicine, Vol. 162, No. 4, 17.02.2015, p. 301-303.

Research output: Contribution to journalArticle

Kuhn, T, Basch, P, Barr, M, Yackel, T, Adler, M, Brahan, R, Cimino, J, Dolin, R, Eisenberg, F, Jirjis, J, Mohammed-Rajput, N, Stottlemyer, D & Wynn, A 2015, 'Clinical documentation in the 21st century: Executive summary of a policy position paper from the American College of Physicians', Annals of Internal Medicine, vol. 162, no. 4, pp. 301-303. https://doi.org/10.7326/M14-2128
Kuhn, Thomson ; Basch, Peter ; Barr, Michael ; Yackel, Thomas ; Adler, Mitchell ; Brahan, Robert ; Cimino, James ; Dolin, Robert ; Eisenberg, Floyd ; Jirjis, Jim ; Mohammed-Rajput, Nareesa ; Stottlemyer, Debra ; Wynn, Alan. / Clinical documentation in the 21st century : Executive summary of a policy position paper from the American College of Physicians. In: Annals of Internal Medicine. 2015 ; Vol. 162, No. 4. pp. 301-303.
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