New Recommendations for Clinical Documentation in EHRs

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The American College of Physicians has issued policy recommendations for improving clinical documentation within electronic health records, which have become overloaded with extraneous data.

“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,” argues a new ACP policy paper published in Annals of Internal Medicine. “At the same time, many physicians and other healthcare professionals have argued that the quality of the systems being used for clinical documentation is inadequate."

ACP makes the case that EHRs have made “defensive documentation easier, which some would interpret as better documentation and others would interpret as a source of ‘note bloat,’ in which key findings and actions are obscured by superfluous negative findings, irrelevant documentation, and differential diagnoses, all of which make the record difficult and time-consuming to read." According to the paper, this has resulted in longer notes but without the increased documentation improving patient care.

“We are in danger of repeating history by overstructuring the clinical record and overloading it with extraneous data,” warns ACP. “Physicians must learn to leverage the enormous and growing capabilities of EHR technology without diminishing or devaluing the importance of narrative entries. Failure to do so will inevitably influence the way we think and teach, to the detriment of patient care.”

ACP asserts that EHRs should be leveraged for what they can do to improve care and documentation, including effectively displaying prior information that shows historical information in rich context; supporting critical thinking; and enabling efficient and effective documentation.

“We believe that physicians must help define and prioritize the many important roles that clinical documentation serves today,” states ACP. “Therefore, this paper proposes a set of guiding principles and actions that can be taken by clinicians, provider institutions, technology vendors, government regulators, payers, and other interested groups to improve the quality and value of clinical documentation and to better use this documentation to improve care.”

ACP offers seven detailed policy recommendations and rationale for clinical documentation and five recommendations and rationale for EHR system design to support “clinical documentation in the 21st Century.” The recommendations, which were approved by ACP’s governing board, were informed by a literature review and input from the various ACP constituencies and non-member experts in the field.

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