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.
