Clinical Notes – Not the Revolution We Were Promised

Clinical documentation has come a long way since the early days of paper records. With the advent of electronic health records (EHRs), the medical community hoped for a more efficient and streamlined process. However, the reality is far from ideal, with traditional clinical notes a significant burden on providers, negatively impacting clinician well-being and patient outcomes.

Historically, clinical notes were intended to serve as a concise record of patient encounters and treatment plans. As healthcare systems grew more complex and regulatory requirements increased, the focus shifted from quality to quantity, leading to a documentation-heavy approach with unintended consequences.

The Flaws of Traditional Notes:

1. Time-consuming: Physicians spend nearly two hours on EHRs and desk work for every hour of direct patient care (Sinsky et al., 2016). This reduces the amount of quality time clinicians spend with patients, leading to rushed encounters and missed diagnoses.

2. Inconsistency: Notes often lack standardization, leading to variations in quality and completeness of information. This can result in communication breakdowns between providers, increasing the risk of medical errors and delayed treatments.

3. Lack of structured data: Unstructured notes hinder the ability to extract meaningful insights and trends from patient data. It becomes challenging to identify population health trends, track quality metrics, and make data-driven decisions.

4. Cognitive burden: The process of writing notes can distract clinicians from focusing on patient interactions and critical thinking. This cognitive burden contributes to clinician burnout, with 42% of physicians reporting burnout due to excessive bureaucratic tasks, including charting and paperwork (Medscape, 2021). This leads to decreased job satisfaction, higher turnover rates, and ultimately, suboptimal patient care.

At River Records, we recognize the critical need for a paradigm shift in clinical documentation. Our AI-powered platform aims to revolutionize the way clinicians document and track patient information, moving beyond the limitations of traditional notes. Healthcare organizations can expect improved clinician satisfaction, better patient outcomes, and increased efficiency. We invite you to join us on this mission to transform patient care and support clinicians in their tireless efforts to improve lives.

Together, let’s find the technological revolution we were promised!

1. Sinsky et al. (2016). Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Annals of internal medicine, 165(11), 753-760.

2. Medscape. (2021). 'Death by 1000 Cuts': Medscape National Physician Burnout & Suicide Report 2021.