Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians

摘要

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.