Over the past several years I’ve written about the inadequate state of clinical documentation, which is largely unchanged since the days of Osler, (except for a bit more structure introduced by Larry Weed in the 1970s) and was created for billing/legal purposes not for care coordination.
One of the most frequent complaints in my email box these days is a sense that the current record is filled with data, but little knowledge and wisdom. It’s hard to understand each patient’s individual story. Notes are filled with cutting/pasting, inaccuracies, and redundancy. Sometimes among the dozen notes written each day by the medical student, resident, fellow, attending, and consultants there is inconsistency.
The era of Ebola has accelerated the urgency for us to rethink the way we document.
In recent lectures, I’ve called on the country to adopt Wikipedia and Facebook for clinical documentation.
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