Medical Documentation in the Electronic Era

摘要

PATIENT-CENTERED CARE (PCC) HAS BEEN EMBRACED by many professional societies. For example, it has been included by the Institute of Medicine as 1 of the 6 goals of quality improvement.1 One aspect of PCC that is being increasingly considered is allowing patients greater access to their medical records.2 However, the adoption of personalized health records (PHRs) has been modest at best.3 There are many challenges to be addressed in PHRs, including the bidirectional flow of data from the PHRs kept by patients to the electronic medical records kept by health care institutions.