Clinical documentation serves several purposes:
To note facts and perceptions that are relevant to diagnosis, investigation or treatment that are too numerous to remember or too complicated
To note relevant positive and negative findings on examination or investigation
To note a rationale for acting or not acting
To plan a course of action
To note the specifics of patient interventions
To signify results
To coordinate multi-specialty care
Documentation serves to make memory unnecessary and helps to make thinking as explicit as possible. Intent, process and outcome need to be as transparent as possible. Clinicians do not, as a rule, explicitly consider the purpose of documentation on a case by case basis.
2 comments:
Hey, Doc, I'd love a kindred spirit!
In the USA, without a national health care service, the chart is sometimes cynically referred to as the "Electronic reimbursement justification record."
I find it useful to think of it instead as part of a collaboration, across space and time, with some past and future people who care about this person's care. It is a "handoff" and, in computer terms, a "load module" to come back later, having flushed your brain of this case, and try to pick up where you left off and get back to where you were when you wrote this sketchy remindner of part of that mental state.
And, sigh, it is a record as much of the caregiver as of the patient, and as such can be sometimes awkward to look back on at a later date. It can be a source of learning and humility about how that small hand waving in the back row was missed or could have been missed, in the sense of patient safefy and Karl Weick's "mindfulness".
And, it is a testament to how little we know about how to record uncertainty and use it well.
But, most of all, I think, it's valuable to ponder this as part of a large-scale collaboration, including the patient and patient family, spanning years and miles, around this one person's health and the context that affects it.
In that view, a "patient portal", Personal Health Record, or actual entries by the patient and their family and friends may be relevant. We just don't have a good way to do that and sort out the pieces.
Despite that, the patient, every patient, has to "do that" and sift through opinions of doctors, nurses, orderlies, cooks, the guy in the lift, friends, family, books, magazines, newspapers, web-sites, television, et.c and decide what to pay attention to and what to ignore.
For chronic care, that part is the most poorly supported part, and yet the most important part for leverage at the point of (self-)care and decisions about that next bite of foot, or going for a walk, or having that cigarette or drink, or just giving it all up.
I agree.
Personally, I am looking forward to domain specific AI for personal health management.
Decision technologies are underfunded, underdeveloped and underdeployed in heathcare.
I am, nevertheless, hopeful!
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