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The map is not the territory: medical records and 21st century practice

机译:地图不属于领土:病历和21世纪的实践

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Documentation of care is at risk of overtaking the delivery of care in terms of time, clinician focus, and perceived importance. The medical record as currently used for documentation contributes to increased cognitive workload, strained clinician-patient relationships, and burnout. We posit that a near verbatim transcript of the clinical encounter is neither feasible nor desirable, and that attempts to produce this exact recording are harmful to patients, clinicians, and the health system. In this Viewpoint, we focus on the alternative constructions of the medical record to bring them back to their primary purpose-to aid cognition, communicate, create a succinct account of care, and support longitudinal comprehensive care-thereby to support the building of relationships and medical decision making while decreasing workload.
机译:就时间,临床医生的关注点和感知到的重要性而言,护理文件有超过医疗服务交付的风险。当前用于文档记录的病历有助于增加认知工作量,紧张的临床医患关系和倦怠。我们认为临床接触的逐字记录是既不可行也不可取的,并且试图产生这种精确的记录对患者,临床医生和卫生系统都是有害的。在此观点中,我们关注病历的替代结构,以使它们回到其主要目的-帮助认知,沟通,创建简洁的护理说明并支持纵向全面护理-从而支持建立关系和医疗决策,同时减少工作量。

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