Skip Navigation
Menu
Editorials |17 February 2015

Clinical Documentation to Improve Patient Care

Thomas D. Sequist, MD, MPH

Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
This article was published online first at www.annals.org on 13 January 2015.
×
FULL TEXT
Expanded use of advanced electronic health records (EHRs) has many implications for the delivery of safe and effective patient care. The benefits of EHRs include decision support promoting medication safety, patient registries for preventive and chronic disease care, and improved patient engagement through integrated patient portals (1). However, these benefits are accompanied by drawbacks, with mixed effects on patient experiences of care (2), the potential for unintended harm related to electronic processes (3), and uncertain return on economic investment in complex EHR implementations (4). In this issue, the Medical Informatics Committee of the American College of Physicians (ACP) provides a policy analysis and recommendations for another important facet of EHRs: clinical documentation (5).
The ACP recommendations revolve around a key concept: Clinical documentation in the era of EHRs should first and foremost support the delivery of care that improves patient care and outcomes. To achieve this goal, providers, payers, policymakers, and EHR developers need to view clinical documentation as a fundamental tool for improving patient care rather than a regulatory burden or gateway for reimbursement. As such, clinical documentation must be integrated into our broadest strategies for ensuring that care is safe and effective.
Achieving this goal requires a vision for clinical documentation that moves beyond the concept of the static clinical note generated by a physician during an office visit or hospital stay. Instead, we must address 3 questions to realize a future of “high-value” clinical documentation. First, who...
FULL TEXT
PDF
Not Available
Citations
Citation

Sequist TD. Clinical Documentation to Improve Patient Care. Ann Intern Med. 2015;162:315–316. doi: https://doi.org/10.7326/M14-2913

Download citation file:

© 2019

×
Permissions

Published: Ann Intern Med. 2015;162(4):315-316.

DOI: 10.7326/M14-2913

4 Citations

Related Articles
Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians
Annals of Internal Medicine; 162 (4): 301-303
Editors' Note: Supplement From the RWJF Clinical Scholars Program
Annals of Internal Medicine; 161 (10): 757
Which Type of Medical Group Provides Higher-Quality Care?
Annals of Internal Medicine; 145 (11): 860-861
Family History Gets a Boost
Annals of Internal Medicine; 156 (4): 315-316
View MoreView Less

Journal Club
Automated reminders and increasing intense support increased uptake of colorectal cancer screening
Annals of Internal Medicine; 158 (12): JC8
Adding a panel manager to EMR reminders improved some preventive care processes
Annals of Internal Medicine; 156 (2): JC1-12
Guideline: USPSTF recommends against menopausal estrogen for primary prevention of chronic conditions
Annals of Internal Medicine; 168 (6): JC26
Review: In older patients with chronic disease, transitional care reduces mortality and readmissions
Annals of Internal Medicine; 167 (6): JC32
View MoreView Less

Related Point of Care
Community-Acquired Pneumonia
Annals of Internal Medicine; 151 (7): ITC4-1
Community-Acquired Pneumonia
Annals of Internal Medicine; 163 (7): ITC1
View MoreView Less

Related Topics
Healthcare Delivery and Policy
Hospital Medicine

Healthcare Delivery and Policy, Hospital Medicine.

PubMed Articles
Patients' experience of wearing multimodal sensor devices intended to detect epileptic seizures: A qualitative analysis.
Epilepsy Behav 2019;
Outcome Measures in Large-Vessel Vasculitis: Relationship Between Patient, Physician, Imaging, and Laboratory-Based Assessments.
Arthritis Care Res (Hoboken) 2019.
View More

Results provided by: PubMed

CONTINUE WITH LIMITED ACCESS
Annals of Internal Medicine
To receive access to the full text of freely available articles, alerts, and more. You will be directed to acponline.org to complete your registration.
×
acp link acp
silverchair link silverchair

Copyright © 2019 American College of Physicians. All Rights Reserved.

Print ISSN: 0003-4819 | Online ISSN: 1539-3704

Privacy Policy

|

Conditions of Use

This site uses cookies. By continuing to use our website, you are agreeing to our privacy policy. | Accept
×

You need a subscription to this content to use this feature.

×
PDF Downloads Require Access to the Full Article.
Annals of Internal Medicine
To receive access to the full text of freely available articles, alerts, and more. You will be directed to acponline.org to complete your registration.
×
Access to this Free Content Requires Users to be Registered and Logged In. Please Choose One of the Following Options
Annals of Internal Medicine
To receive access to the full text of freely available articles, alerts, and more. You will be directed to acponline.org to complete your registration.
×