TY - JOUR
T1 - It’s time to change our documentation philosophy
T2 - writing better neurology notes without the burnout
AU - Rodríguez-Fernández, Jorge M.
AU - Loeb, Jeffrey A.
AU - Hier, Daniel B.
N1 - Funding Information:
JAL was supported in part by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health, through Grant Award Number UL1TR002003 (JAL). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Publisher Copyright:
2022 Rodríguez-Fernández, Loeb and Hier.
PY - 2022/11/28
Y1 - 2022/11/28
N2 - 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.
AB - 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.
KW - clinician well-being
KW - documentation burden
KW - electronic health records
KW - evaluation and management coding
KW - medical decision-making
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U2 - 10.3389/fdgth.2022.1063141
DO - 10.3389/fdgth.2022.1063141
M3 - Article
AN - SCOPUS:85143973916
SN - 2673-253X
VL - 4
JO - Frontiers in Digital Health
JF - Frontiers in Digital Health
M1 - 1063141
ER -