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Beyond Notes: Why It Is Time to Abandon an Outdated Documentation Paradigm
Author(s) -
Jackson Steinkamp,
Jacob Kantrowitz,
Abhinav Sharma,
Wasif Bala
Publication year - 2021
Publication title -
jmir. journal of medical internet research/journal of medical internet research
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.446
H-Index - 142
eISSN - 1439-4456
pISSN - 1438-8871
DOI - 10.2196/24179
Subject(s) - documentation , computer science , chart , workspace , paradigm shift , electronic health record , health care , data science , organizational chart , artificial intelligence , philosophy , statistics , mathematics , epistemology , robot , economics , programming language , economic growth , systems engineering , engineering
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.

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