Review
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

https://doi.org/10.1016/j.ijmedinf.2014.12.001Get rights and content

Highlights

  • Documentation takes 25–50% of clinicians’ time.

  • There has been almost research into the value documentation for patient care.

  • Currently there is no evidence that either paper or electronic documentation benefits patients.

Abstract

Background

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.

Introduction

In 1964 Dr Laurence Weed published his first article on the problem oriented medical record in the Irish Journal of Medical Science [1]. At that time a consultation in hospital from a medical specialist consisted of a detailed history that may have taken up to 20 min, followed by a comprehensive physical examination that usually took another 10 min. The junior doctor would then be asked if there were any abnormalities in the urine, and if he had looked at the blood smear. A chest X-ray may have been available for review, and there may have been a brief discussion on what an ECG tracing may or may not reveal, and if it were worth doing. The consultant would then write the patient's diagnosis in the chart and prescribe treatment. Over 90% of the total time spent on the consultation was at the patient's bedside. Compare this to a modern day consultation during which little time is spent with the patient [2], [3], [4], and most spent trawling through the patients chart, determining what investigations and treatments have already been done, what other physicians thought, what numerous paramedical assessments suggested, what medication the patient is on, has been on, and can or cannot take etc.

Over the years the amount of documentation routinely recorded at every medical encounter has grown exponentially so that it now occupies a quarter [2], [4] to half [5] of doctors’ time. At the Hospital for Sick Children's intensive care unit in Toronto documentation increased by 25% from 1999 to 2005 by which time 1348 items of information were documented on each patient every 24 h [6]. In the United Kingdom [7] and Australia [8] nurses spend approximately 20% of their time on documentation and in the United States every hour of patient care now requires from 30 min to 60 min of paperwork [7], [9], [10]. Even the most trivial clinical episode, which a generation ago would have warranted only a brief note scribbled on a small card, now requires several pages of forms containing voluminous information of dubious or unproven value [11], [12], [13], [14]. Collection of this data is time consuming and, therefore, detracts from patient care. Time spent analyzing and completing documentation reduces the amount of quality time that a physician has to care for their patient and their relatives, not to mention teaching and clinical research [15]. Whilst there is an obvious need for medical documentation its recent increase has been driven by administrators and their legal advisors without any evidence that it improves medical care, and a culture is developing in which documentation of care has become more important than its actual delivery [16]. Much of this documentation has been mandated by the common but mistaken assumption that complex systems like health care can be made safer by adding more complexity [17]. Although originally introduced to help the clinicians’ memory and organize their thought processes, the medical record now may often be more of a hindrance than a help to patient care. Even though it takes up such a large part of all clinicians’ working day the medical literature on documentation and its value is sparse. Medline searches on May 7th 2014 combining the terms medical records, documentation, time, and value or efficacy or benefit yielded only 147 articles, most which were commentaries and editorials. This review is based on 43 relevant articles selected from this search and additional studies gathered from our personal experience and that of our colleagues – of these only 38 papers were peer reviewed original research (Table 1).

Section snippets

Information overload – getting less out of more

Traditionally only one doctor was the primary author of the medical record. As medical care has become more complex and fragmented medical records now have multiple contributors, so the record has become organized into different sections that each of the multiple users of the chart can quickly find. For doctors there is the admission note, the history and physical, progress notes, doctors’ orders and consultations. Nurses in particular are now required to complete a considerable amount of

Will computers help? Pros and cons

Paper charts have obvious limitations such as fragmentation of patient data, missing records and poor legibility that can be partly addressed by an electronic medical record (EMR) system. However, despite the widespread use of computer technology in other industries many medical records still use the traditional paper chart [20]. In 2009 only 1.5% of U.S. hospitals had a comprehensive electronic-records (EMR) system (i.e., present in all clinical units), although 7.6% did have a basic system

The EMR of the future – can they get more out of less?

Although physicians may think that performing a history and physical, ordering investigations, making a diagnosis and devising a treatment plan are separate processes, in reality they are all interconnected and each is driven and modulated by each of the others. Even the most experienced clinicians find organizing and planning these processes efficiently difficult, especially if the patient has multiple complex conditions that are unstable and changing rapidly.

As more and more information is

Point-of-care documentation

The introduction of the tablet computer now makes it possible for patient information to be entered promptly at the bedside and then immediately disseminated via the EMR to everyone responsible for the patient's welfare [73]. This means that any change in the patient's condition should be quickly recognized and appropriately managed. Technology alone, however, will not lead to “a world of real-time information.” [42]: for this to take place nursing documentation culture must change. Nurses will

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. Instead physicians have passively allowed administrators and regulators to impose ever increasing documentation on them and shown little interest in studying its potential benefits for and threats to patient care. It is almost 45 years since Dr Weed proposed numerous

Author contributions

Both authors contributed to this paper by performing repeated literature and internet searches as well as prolonged discussions and debates with their medical and information technology colleagues.

Conflict of interest

This paper received no funding from any third party and neither of the authors has any conflict of interest.

Summary points

  • Documentation now occupies a quarter to half of doctors’ time yet much of the information collected is of dubious or unproven value.

  • The medical literature on documentation and its value is sparse. Medline searches combining the terms medical records, documentation, time, and value or efficacy or benefit yielded only 147 articles.

  • Although electronic medical records (EMRs)

References (83)

  • A.M. van Ginneken

    The computerized patient record: balancing effort and benefit

    Int. J. Med. Inf.

    (2002)
  • S.T. Rosenbloom et al.

    Interface terminologies: facilitating direct entry of clinical data into electronic health record systems

    J. Am. Med. Inform. Assoc.

    (2006)
  • M.J. van der Meijden et al.

    An experimental electronic patient record for stroke patients. Part 2: System description

    Int. J. Med. Inf.

    (2000)
  • C.R. Weir et al.

    An exploration of the impact of computerized patient documentation on clinical collaboration

    Int. J. Med. Inf.

    (2011)
  • I.G. Stiell et al.

    Methodologic standards for the development of clinical decision rules in emergency medicine

    Ann. Emerg. Med.

    (1999)
  • R. Krumm et al.

    The need for harmonized structured documentation and chances of secondary use – results of a systematic analysis with automated form comparison for prostate and breast cancer

    J. Biomed. Inform.

    (2014)
  • D. Prytherch et al.

    Calculating early warning scores—a classroom comparison of pen and paper and hand-held computer methods

    Resuscitation

    (2006)
  • L.L. Weed et al.

    Ir. J. Med. Sci.

    (1964)
  • E. Ammenwerth et al.

    The time needed for clinical documentation versus direct patient care. A work-sampling analysis of physicians’ activities

    Methods Inf. Med.

    (2009)
  • A.S. Oxentenko et al.

    Time spent on clinical documentation

    Arch. Intern. Med.

    (2010)
  • L.M. Füchtbauer et al.

    Emergency department physicians spend only 25% of their working time on direct patient care

    Dan. Med. J.

    (2013)
  • UK best practice nursing database – personal communication courtesy of Dr Keith...
  • M.A. Ballermann et al.

    Validation of the work observation method by activity timing (WOMBAT) method of conducting time-motion observations in critical care settings: an observational study

    BMC Med. Inf. Decis. Mak.

    (2011)
  • American Hospital Association et al.

    Patients or Paperwork? The Regulatory Burden Facing America's Hospitals

    (2001)
  • A. Sainsbury et al.

    Reliability of the Barthel index when used in older people

    Age Ageing

    (2005)
  • P.L. Pancorbo-Hidalgo et al.

    Risk assessment scales for pressure ulcer prevention: a systematic review

    J. Adv. Nurs.

    (2006)
  • D. Oliver et al.

    Falls risk prediction tools for hospital inpatients: do they work?

    Nurs. Times

    (2009)
  • Excessive paperwork detracts from patient care, professional mentoring, and research

    Oncology

    (2001)
  • Electronic Nursing Documentation: Charting New Territory. Medscape

    (2013)
  • C. Perrow

    Normal Accidents: Living with High-Risk Technologies

    (1984)
  • G. Hripcsak et al.

    Use of electronic clinical documentation: time spent and team interactions

    J. Am. Med. Inform. Assoc.

    (2011)
  • A. Hickey et al.

    READS: the rapid electronic assessment documentation system

    Br. J. Nurs.

    (2012)
  • D. Blumenthal et al.

    The Federal Role in Promoting Health Information Technology

    (2009)
  • A.K. Jha et al.

    Use of electronic health records in U.S. hospitals

    N. Engl. J. Med.

    (2009)
  • D. Blumenthal

    Launching HITECH

    N. Engl. J. Med.

    (2010)
  • C.-J. Hsiao et al.

    Use and Characteristics of Electronic Health Record Systems Among Office-based Physician Practices: United States, 2001–2013. NCHS Data Brief, No 143

    (2014)
  • D. Charles et al.

    Adoption of Electronic Health Record Systems Among U.S. Non-federal Acute Care Hospitals: 2008–2013. ONC Data Brief, No. 16

    (2014)
  • M.W. Friedberg, P.G. Chen, K.R. Van Busum, F. Aunon, C. Pham, J. Caloveras, S. Mattke, E. Pitchforth, D.D. Quigley,...
  • A.S. O’Malley et al.

    Are electronic medical records helpful for care coordination? Experiences of physician practices

    J. Gen. Intern. Med.

    (2010)
  • R. Fernandopulle et al.

    How the electronic health record did not measure up to the demands of our medical home practice

    Health Aff.

    (2010)
  • N. Menachemi et al.

    Benefits and drawbacks of electronic health record systems

    Risk Manag. Healthc. Policy

    (2011)
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