Question

Make 2-3 paragraphs of recommendations and an abstract about the CLINICAL in 21st century (Academic report)

Answer 1

Clinical documentation was developed to track a patient's condition and communicate the author's actions and thoughts to other members of the care team. Over time, other stakeholders have placed additional requirements on the clinical documentation process for purposes other than direct care of the patient. More recently, new information technologies, such as electronic health record (EHR) systems, have led to further changes in the clinical documentation process. Although computers and EHRs can facilitate and even improve clinical documentation, their use can also add complexities; new challenges; and, in the eyes of some, an increase in inappropriate or even fraudulent documentation. At the same time, many physicians and other health care professionals have argued that the quality of the systems being used for clinical documentation is inadequate. The Medical Informatics Committee of the American College of Physicians has undertaken this review of clinical documentation in an effort to clarify the broad range of complex and interrelated issues surrounding clinical documentation and to suggest a path forward such that care and clinical documentation in the 21st century best serve the needs of patients and families.

At its most fundamental level, the clinical encounter between a patient and their doctor seeks to solve a mystery. Clinicians uncover clues through the history,and ancillary tests to arrive at a diagnosis and develop a management plan. Despite advances in technology, the majority of clinical diagnoses are still reached through the history and physical examination without the use of laboratory and imaging tests. However, in the modern American hospital, clinicians spend as little as 12% of their time in direct contact with patients and their families. This has led to a decline in clinical examination skills and contributes to diagnostic error. There is a growing movement to return clinicians and trainees back to the bedside. In 2017, we formed the Society of Bedside Medicine to encourage innovation, education, and research on the role of the clinical encounter in 21st century medicine. Over the last 3 years, we have embraced the following 6 strategies to reinvigorate the practice of the clinical examination: 1) be present with the patient; 2) practice an evidence‑based approach to the physical exam; 3) create opportunities for intentional practice of the physical exam; 4) recognize the power of the physical examination beyond diagnosis; 5) use point‑of‑care technology to aid in diagnosis and reinforce skills; and 6) seek and provide specific feedback on physical examination skills. By employing these strategies in both teaching and practice, clinicians can maximize the value of time spent with patients and renew the importance of the clinical examination in 21st century practice.

CLINICAL DOCUMENTATION IN THE 21ST CENTURY
Policy Recommendations for Clinical Documentation
Position 1: The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.
Position 2: Physicians working with their care delivery organizations, medical societies, and others, should define professional standards regarding clinical documentation practices throughout their organizations. Further, clinical usefulness of health information exchange (HIE) will be facilitated by appropriate re-design of clinical documentation based on consensus-driven professional standards unique to individual specialties as a result of collaboration with standards setting organizations.
A. The clinical record should include the patient’s story in as much detail as is required to retell the story.
B. When used appropriately, macros and templates may be valuable in improving the completeness and efficiency of documentation, particularly where that documentation is primarily limited to standardized terminology, such as the Review of Systems and Physical findings
C. The EHR should facilitate thoughtful review of previously documented clinical information. Ready review of prior relevant information, such as longitudinal history and care plans, as well as prior physical findings may be valuable in improving the completeness of documentation, as well as establishing context.
D. . Where previously documented clinical information is still accurate and adds to the value of current documentation, this process of “review/edit and/or attest, and then copy/forward” of specific prior history or findings may improve the accuracy, completeness, and efficiency of documentation. However these documentation techniques can also be misused – to the detriment of accuracy, high quality care, and patient safety.
E. Effective and ongoing EHR documentation training of clinical personnel should be an ongoing process.

Position 3: As value-based care and accountable care models grow, the primary purpose of the EHR should remain the facilitation of seamless patient care to improve outcomes while contributing to data collection that supports necessary analyses.
Position 4: Structured data should be captured only where they are useful in care delivery, or essential for quality assessment or reporting.
Position 5: Prior authorizations, as well as all other documents required by other entities must no longer be unique in their data content and format requirements.
Position 6: Patient access to progress notes, as well as the rest of their medical records may offer a way to improve both patient engagement and quality of care.
Position 7: The College calls for further research to:
A. Identify best practices for systems and clinicians to improve accuracy of information
recorded and the value of information presented to other users.
B. Study the authoring process and encourage the development of automated tools that
enhance documentation quality without facilitating improper behaviors.
C. Understand the best way to improve medical education to prepare new and practicing clinicians for the growing uses of health information technology in the care of patients
and populations and to recognize the importance of their responsibility to document their observations completely, concisely, accurately, and in a way that support their reuse.
D. Determine the most effective methods of disseminating professional standards of clinical documentation and best practices.
Policy Recommendations for EHR System Design to Support 21st Century Clinical Documentation
Position 1: EHR developers need to optimize EHR systems to facilitate longitudinal care delivery, as well as care that involves teams of clinicians.
Position 2: Clinical documentation in EHR systems must support clinicians’ cognitive processes during the documentation process.
Position 3: EHRs must support “write once – reuse many times” and embed tags to identify the original source of information when used subsequent to its first creation.
Position 4: Wherever possible, EHR systems should not require users to check a box or otherwise indicate that an observation has been made or an action has been taken if the data documented in the patient record already substantiate the action.
Position 5: EHR systems must facilitate the integration of patient generated data, and must maintain the identity of source.