Beyond Notes: Why It Is Time to Abandon an Outdated Documentation Paradigm

Research
Written By Jackson Steinkamp

Authors: Jackson Steinkamp; Jacob Kantrowitz; Abhinav Sharma; Wasif Bala

Published: April 2021 4/20/2021

Journal: Journal of Medical Internet Research (JMIR)

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.

Jackson Steinkamp
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