Clinical Documentation to Improve Patient Care
Authors: Thomas D. Sequist
Journal: Annals of Internal Medicine (2015)

Editorials17 February 2015Clinical Documentation to Improve Patient CareThomas D. Sequist, MD, MPHThomas D. Sequist, MD, MPHFrom Partners Healthcare System, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M14-2913 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Expanded use of advanced electronic health records (EHRs) has many implications for the delivery of safe and effective patient care. The benefits of EHRs include decision support promoting medication safety, patient registries for preventive and chronic disease care, and improved patient engagement through integrated patient portals (1). However, these benefits are accompanied by drawbacks, with mixed effects on patient experiences of care (2), the potential for unintended harm related to electronic processes (3), and uncertain return on economic investment in complex EHR implementations (4). In this issue, the Medical Informatics Committee of the American College of Physicians (ACP) provides a ...References1. Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff (Millwood). 2011;30:464-71. [PMID: 21383365] doi:10.1377/hlthaff.2011.0178 CrossrefMedlineGoogle Scholar2. Kazmi Z. Effects of exam room EHR use on doctor-patient communication: a systematic literature review. Inform Prim Care. 2013;21:30-9. [PMID: 24629654] doi:10.14236/jhi.v21i1.37 CrossrefMedlineGoogle Scholar3. Allen AS, Sequist TD. Pharmacy dispensing of electronically discontinued medications. Ann Intern Med. 2012;157:700-5. [PMID: 23165661] doi:10.7326/0003-4819-157-10-201211200-00006 LinkGoogle Scholar4. Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144:742-52. [PMID: 16702590] doi:10.7326/0003-4819-144-10-200605160-00125 LinkGoogle Scholar5. Kuhn T, Basch P, Barr M, Yackel T; Medical Informatics Committee of the American College of Physicians. Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2015;162:301-3. doi:10.7326/M14-2128 LinkGoogle Scholar6. Delbanco T, Walker J, Bell SK, Darer JD, Elmore JG, Farag N, et al. Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead. Ann Intern Med. 2012;157:461-70. [PMID: 23027317] doi:10.7326/0003-4819-157-7-201210020-00002 LinkGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From Partners Healthcare System, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts.Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2913.Corresponding Author: Thomas D. Sequist, MD, MPH, Partners Healthcare System, Prudential Tower, 800 Boylston Street, Suite 1150, Boston, MA 02199; e-mail, [email protected]org.This article was published online first at www.annals.org on 13 January 2015. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoClinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians Thomson Kuhn , Peter Basch , Michael Barr , Thomas Yackel , and Metrics Cited ByRationale and design of the Novel Uses of adaptive Designs to Guide provider Engagement in Electronic Health Records (NUDGE-EHR) pragmatic adaptive randomized trial: a trial protocolUnsafe nursing documentation: A qualitative content analysisEvaluating the impact of an electronic application of the Dynamic Appraisal of Situational Aggression with an embedded Aggression Prevention Protocol on aggression and restrictive interventions on a forensic mental health unitParticipants' perceptions of an intervention implemented in an Action Research Nursing Documentation Project 17 February 2015Volume 162, Issue 4Page: 315-316KeywordsElectronic medical recordsHealth careHealth information technologyHospitalizationsPatientsPopulation statisticsQuality improvementSafetyTriageVision ePublished: 17 February 2015 Issue Published: 17 February 2015 CopyrightCopyright © 2015 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...