Association of Medical Directors of Information Systems consensus on inpatient electronic health record documentation.
In 2013, electronic documentation of clinical care stands at a crossroads. The benefits of creating digital notes are at risk of being overwhelmed by the inclusion of easily importable detail. Providers are the primary authors of encounters with patients. We must document clearly our understanding of patients and our communication with them and our colleagues. We want to document efficiently to meet without exceeding documentation guidelines. We copy and paste [...]
Author(s): Shoolin, J, Ozeran, L, Hamann, C, Bria, W
DOI: 10.4338/ACI-2013-02-R-0012