Int J Med Inform - Medical documentation: part of the solution, or part of the problem? A narrative review of the literature on the time spent on and value of medical documentation.

Tópicos

{ record(1888) medic(1808) patient(1693) }
{ search(2224) databas(1162) retriev(909) }
{ howev(809) still(633) remain(590) }
{ error(1145) method(1030) estim(1020) }
{ system(1050) medic(1026) inform(1018) }
{ method(1557) propos(1049) approach(1037) }
{ can(774) often(719) complex(702) }
{ health(3367) inform(1360) care(1135) }
{ decis(3086) make(1611) patient(1517) }
{ chang(1828) time(1643) increas(1301) }
{ studi(1119) effect(1106) posit(819) }
{ monitor(1329) mobil(1314) devic(1160) }
{ ehr(2073) health(1662) electron(1139) }
{ drug(1928) target(777) effect(648) }
{ assess(1506) score(1403) qualiti(1306) }
{ research(1085) discuss(1038) issu(1018) }
{ research(1218) medic(880) student(794) }
{ use(2086) technolog(871) perceiv(783) }
{ imag(2830) propos(1344) filter(1198) }
{ patient(2315) diseas(1263) diabet(1191) }
{ take(945) account(800) differ(722) }
{ studi(2440) review(1878) systemat(933) }
{ concept(1167) ontolog(924) domain(897) }
{ care(1570) inform(1187) nurs(1089) }
{ featur(1941) imag(1645) propos(1176) }
{ data(3963) clinic(1234) research(1004) }
{ time(1939) patient(1703) rate(768) }
{ patient(1821) servic(1111) care(1106) }
{ can(981) present(881) function(850) }
{ high(1669) rate(1365) level(1280) }
{ survey(1388) particip(1329) question(1065) }
{ method(1969) cluster(1462) data(1082) }
{ model(3404) distribut(989) bayesian(671) }
{ imag(1947) propos(1133) code(1026) }
{ data(1737) use(1416) pattern(1282) }
{ inform(2794) health(2639) internet(1427) }
{ system(1976) rule(880) can(841) }
{ measur(2081) correl(1212) valu(896) }
{ imag(1057) registr(996) error(939) }
{ bind(1733) structur(1185) ligand(1036) }
{ sequenc(1873) structur(1644) protein(1328) }
{ method(1219) similar(1157) match(930) }
{ featur(3375) classif(2383) classifi(1994) }
{ network(2748) neural(1063) input(814) }
{ imag(2675) segment(2577) method(1081) }
{ motion(1329) object(1292) video(1091) }
{ treatment(1704) effect(941) patient(846) }
{ surgeri(1148) surgic(1085) robot(1054) }
{ framework(1458) process(801) describ(734) }
{ problem(2511) optim(1539) algorithm(950) }
{ learn(2355) train(1041) set(1003) }
{ clinic(1479) use(1117) guidelin(835) }
{ algorithm(1844) comput(1787) effici(935) }
{ extract(1171) text(1153) clinic(932) }
{ data(1714) softwar(1251) tool(1186) }
{ design(1359) user(1324) use(1319) }
{ control(1307) perform(991) simul(935) }
{ model(2220) cell(1177) simul(1124) }
{ general(901) number(790) one(736) }
{ method(984) reconstruct(947) comput(926) }
{ case(1353) use(1143) diagnosi(1136) }
{ studi(1410) differ(1259) use(1210) }
{ risk(3053) factor(974) diseas(938) }
{ perform(999) metric(946) measur(919) }
{ import(1318) role(1303) understand(862) }
{ model(2341) predict(2261) use(1141) }
{ visual(1396) interact(850) tool(830) }
{ compound(1573) activ(1297) structur(1058) }
{ perform(1367) use(1326) method(1137) }
{ blood(1257) pressur(1144) flow(957) }
{ spatial(1525) area(1432) region(1030) }
{ model(3480) simul(1196) paramet(876) }
{ state(1844) use(1261) util(961) }
{ patient(2837) hospit(1953) medic(668) }
{ model(2656) set(1616) predict(1553) }
{ data(2317) use(1299) case(1017) }
{ age(1611) year(1155) adult(843) }
{ medic(1828) order(1363) alert(1069) }
{ signal(2180) analysi(812) frequenc(800) }
{ cost(1906) reduc(1198) effect(832) }
{ group(2977) signific(1463) compar(1072) }
{ sampl(1606) size(1419) use(1276) }
{ gene(2352) biolog(1181) express(1162) }
{ data(3008) multipl(1320) sourc(1022) }
{ first(2504) two(1366) second(1323) }
{ intervent(3218) particip(2042) group(1664) }
{ activ(1138) subject(705) human(624) }
{ analysi(2126) use(1163) compon(1037) }
{ health(1844) social(1437) communiti(874) }
{ structur(1116) can(940) graph(676) }
{ cancer(2502) breast(956) screen(824) }
{ use(976) code(926) identifi(902) }
{ use(1733) differ(960) four(931) }
{ result(1111) use(1088) new(759) }
{ implement(1333) system(1263) develop(1122) }
{ estim(2440) model(1874) function(577) }
{ process(1125) use(805) approach(778) }
{ activ(1452) weight(1219) physic(1104) }
{ method(2212) result(1239) propos(1039) }
{ detect(2391) sensit(1101) algorithm(908) }

Resumo

CKGROUND: Even though it takes up such a large part of all clinicians' working day the medical literature on documentation and its value is sparse.METHODS: Medline searches combining the terms medical records, documentation, time, and value or efficacy or benefit yielded only 147 articles. This review is based on the relevant articles selected from this search and additional studies gathered from the personal experience of the authors and their colleagues.RESULTS: Documentation now occupies a quarter to half of doctors' time yet much of the information collected is of dubious or unproven value. Most medical records departments still use the traditional paper chart, and there is considerable debate on the benefits of electronic medical records (EMRs). Although EMRs contains a lot more information than a paper record clinicians do not find it easy to getting useful information out of them. Unlike the paper chart narrative is difficult to enter into most EMRs so that they do not adequately communicate the patient's "story" to clinicians. Recent innovations have the potential to address these issues.CONCLUSION: Although documentation is widespread throughout the health care industry there has been almost no formal research into its value, on how to enhance its value, or on whether the time spent on it has negative effects on patient care.

Resumo Limpo

ckground even though take larg part clinician work day medic literatur document valu sparsemethod medlin search combin term medic record document time valu efficaci benefit yield articl review base relev articl select search addit studi gather person experi author colleaguesresult document now occupi quarter half doctor time yet much inform collect dubious unproven valu medic record depart still use tradit paper chart consider debat benefit electron medic record emr although emr contain lot inform paper record clinician find easi get use inform unlik paper chart narrat difficult enter emr adequ communic patient stori clinician recent innov potenti address issuesconclus although document widespread throughout health care industri almost formal research valu enhanc valu whether time spent negat effect patient care

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