It's time to change our documentation philosophy: writing better neurology notes without the burnout

被引:7
作者
Rodriguez-Fernandez, Jorge M. [1 ]
Loeb, Jeffrey A. [2 ]
Hier, Daniel B. [2 ,3 ]
机构
[1] Univ Texas Med Branch, Dept Neurol, Galveston, TX 77555 USA
[2] Univ Illinois, Dept Neurol & Rehabil, Chicago, IL USA
[3] Missouri Univ Sci & Technol, Dept Elect & Comp Engn, Rolla, MO USA
来源
FRONTIERS IN DIGITAL HEALTH | 2022年 / 4卷
基金
美国国家卫生研究院;
关键词
electronic health records; documentation burden; clinician well-being; evaluation and management coding; medical decision-making; ELECTRONIC HEALTH RECORD; CLINICAL DOCUMENTATION; CAREER SATISFACTION; PHYSICIAN; RESIDENTS; IMPACTS; SPENT;
D O I
10.3389/fdgth.2022.1063141
中图分类号
R19 [保健组织与事业(卫生事业管理)];
学科分类号
摘要
Succinct clinical documentation is vital to effective twenty-first-century healthcare. Recent changes in outpatient and inpatient evaluation and management (E/M) guidelines have allowed neurology practices to make changes that reduce the documentation burden and enhance clinical note usability. Despite favorable changes in E/M guidelines, some neurology practices have not moved quickly to change their documentation philosophy. We argue in favor of changes in the design, structure, and implementation of clinical notes that make them shorter yet still information-rich. A move from physician-centric to team documentation can reduce work for physicians. Changing the documentation philosophy from "bigger is better" to "short but sweet" can reduce the documentation burden, streamline the writing and reading of clinical notes, and enhance their utility for medical decision-making, patient education, medical education, and clinical research. We believe that these changes can favorably affect physician well-being without adversely affecting reimbursement.
引用
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页数:6
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