Beyond notes: Why it is time to abandon an outdated documentation paradigm

• Type of Material: Article
• Authors: Jackson Steinkamp, University of Pennsylvania; Jacob Kantrowitz, Carney Hospital; Abhinav Sharma, University of Toronto; Wasif Bala, Emory University
• Language: English
• Date: 2021-04-01
• Publisher: JMIR
• Publication Version: Final Published Version
• Copyright Statement: ©Jackson Steinkamp, Jacob Kantrowitz, Abhinav Sharma, Wasif Bala. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 20.04.2021.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.2196/24179
• Title of Journal or Parent Work: Journal of Medical Internet Research
• Volume: 23
• Issue: 4
• Start Page: e24179
• End Page: e24179
• Keywords: medical team; medical notes; electronic medical notes; medical documentation; clinicians; electronic medical records; information chaos; health informatics
• Research Categories: Health Sciences, Health Care Management

Abstract

Clinicians spend a substantial part of their workday reviewing and writing electronic medical notes. Here we describe how the current, widely accepted paradigm for electronic medical notes represents a poor organizational framework for both the individual clinician and the broader medical team. As described in this viewpoint, the medical chart-including notes, labs, and imaging results-can be reconceptualized as a dynamic, fully collaborative workspace organized by topic rather than time, writer, or data type. This revised framework enables a more accurate and complete assessment of the current state of the patient and easy historical review, saving clinicians substantial time on both data input and retrieval. Collectively, this approach has the potential to improve health care delivery effectiveness and efficiency.