The American College of Physicians (ACP) tackles the complexities of clinical documentation within electronic health records (EHR) in a new policy position paper published in Annals of Internal Medicine. “Clinical Documentation in the 21st Century: A Policy Position Paper from the American College of Physicians” outlines a set of guiding principles and actions to help clinicians, provider institutions, technology vendors, government regulators, payers, and other interested groups to improve the quality of clinical documentation and to better use this documentation to improve care.
Clinical documentation is used to document and track a patient’s condition and communicate treatment decisions and commentary to other members of the care team, and more recently, to the patient. Defensive medicine and evaluation and management coding (E&M) guidelines have added substantial pressure to modify both the format and content of documentation. The EHR has added further challenges, but also opportunities. Authors of the ACP policy paper argue that EHR should be leveraged for what it can do to improve care and documentation, including effectively displaying prior information that shows historical information in rich context; supporting critical thinking; enabling efficient and effective documentation; and supporting appropriate and secure sharing of useful and usable information with others, including patients, families, and caregivers. E&M mandated documentation format and verbosity and EHR mandated structured data entry have introduced barriers to efficiently documenting narrative entries, and may further be barriers to the use of documentation to improve care.
In its policy paper, ACP offers seven detailed policy recommendations and rationale for clinical documentation and five recommendations and rationale for EHR system design to support 21st century clinical documentation. The recommendations were informed by a literature review and input from the various College constituencies and nonmember experts in the field. The full paper and an executive summary are published together online.
Source: American College of Physicians