Clinical Documentation and the Health Record: The Essay

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Clinical Documentation and the Health Record:

The adoption of computerized records is seen as the most appropriate means of improving the quality of care while decreasing health care costs. However, the main concern is on how to design the most suitable and effective electronic health records that improves the workflow of clinicians. While clinical documentation is integral in electronic health records and accounts for a considerable portion of physicians' time, its practices have largely been dominated with legal and billing requirements. Through the effective implementation of electronic clinical documentation, it will be possible to not only lessen the rate of medication errors but it will also help in achievement of other benefits. This method of documentation has been characterized with various concerns including whether it can be leveraged to enhance the quality of care without negative impacts on the efficiency of clinicians.

Electronic Health Records can help in lessening diagnostic errors through various ways including sorting, arranging, and providing access to information.

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The ability of physicians to provide accurate diagnoses is usually dependent on meticulousness in collecting patient's information from medical history and physical examination. Unlike the use of paper records, electronic health records will increase the timely accessibility of patients' information and enhance the clinician's knowledge about the patient. Secondly, these records can strengthen thoughtful examination by providing document succinct analysis to both clinicians and patients. Clinical documentation that promotes thoughtful examination should be based on efficient text-entry tools (Schiff & Bates par, 5).

Electronic health record systems can also reduce medical errors by promoting the documentation of ongoing patient history and assessment with which patients will not be required to begin a record from scratch with every new physician. In addition these systems should be developed with a better approach to managing problem lists through incorporating….....

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