Sorry if I went afield. I think my answer got a bit rambly. I appreciate you clarifying what you're aiming for, and I'll try to edit this response to the same level of clarity. Hopefully.

I'm going to have to give my response in a couple of posts, since HN says it was too long.

> My outside knowledge is that a medical facility focuses on: diagnosis, confirmation of diagnosis, selection of treatment along with annotations about EXCEPTIONS to standard treatment, finally actual treatment

The first thing to clarify is: there are a number of different types of medical facilities, ranging from private primary care to massive, regional specialty care hospitals, and the modifications to the above really depend on what type we're discussing. I'll pitch my answer to small-to-mid-sized secondary care (bread and butter specialty care like cardiology; general surgery, some onco surgery; little or no sub-specialty care) because that's the most commonly encountered facility. That's with the caveat that, again, the answer to that is different from other facilities (e.g., your family care practice) that are just as important to discuss.

Your list of things facilities focus on is correct except for your idea of annotations of exceptions. Our documentation focuses on the entirety of the patient encounter, all of the physical and laboratory exam findings we consider pertinent, our treatment choices, and often some degree of our treatment rationale. Outside observers often think "well, don't you just give a standard CHF treatment to someone with CHF, unless there's an exception?" A large purpose of our standard documentation is to provide an outside observer the chance to recreate how we came to our conclusions regarding diagnosis and the best course of treatment. In short, we document to cover our asses from malpractice.

Second, we document so that the hospital can bill insurers. Insurers create increasingly specific requirements for what must have been done or detected before a service can be provided - and those things must be in our note (or else the insurer assumes it didn't happen), and must be linked in our writing (Patient had finding X therefore we did Y). Increasingly, if one doesn't link it, they argue that they couldn't infer that Y was because of X. (That comes up more with performance metrics - oh, you told the patient to lose weight? We didn't realize that was meant to be an intervention for being overweight. We can't just assume what you mean to be treating.)

Lastly, we document for government and insurer mandated performance metrics. For instance, I need to do a depression screening for all over-65s annually. So, a helpful person working on our EMR built-in a reminder tab - did you do a depression screening today? I have to go through a drop-down to select "No", and then another for reason why ("Already Performed", "Patient Not Eligible", "Patient Already Diagnosed with Depression") about 30 times a day. That's our simplest metric, and one of dozens (because there's not a consistent set of metrics across all insurers.) You're about to suggest a way that this can be automated to suck less. I can suggest that, too, but as you may have noticed, this program is paid for by the hospital, to benefit the hospital's performance with insurers and the government. Physicians aren't the customers. Dev time is committed to making it suck less for us only enough to keep us from storming the hospital with pitchforks and catapults hurling ICD10 printouts.

And, lastly, something I truly didn't understand when I worked in health insurance but I do now: there's absolutely no such thing as a standard patient, plus or minus exceptions. The reason for that is because there's no such thing as "a patient with CHF". There's "a patient with history X, which leads me to believe they have CHF subtype 2C, with complications X, Y, Z, and complicating factors 1 and 2." Good doctors keep all diagnoses provisional, because the evolution over time will absolutely change your understanding of the patient - whether to CHF subtype 1Zebra or because what you thought was Complication Y and Z was actually parallel disease Ampersand. This is why we constantly communicate the story of the patient's history to one another, and why every doc takes their own history. Accepting a diagnosis from someone at hand-off is called a "chart rumor," and making a habit of it is a fantastic way of mis-treating patients. I cannot possibly tell you how many times I've improved patient care by just starting over from zero rather than accepting a chart rumor.