Succinct Clinical Documentation is Vital to Effective Twenty-First-Century Healthcare. Recent Changes in Outpatient and Inpatient Evaluation and Management (E/M) Guidelines Have Allowed Neurology Practices to Make Changes that Reduce the Documentation Burden and Enhance Clinical Note Usability. Despite Favorable Changes in E/M Guidelines, Some Neurology Practices Have Not Moved Quickly to Change their Documentation Philosophy. We Argue in Favor of Changes in the Design, Structure, and Implementation of Clinical Notes that Make Them Shorter Yet Still Information-Rich. a Move from Physician-Centric to Team Documentation Can Reduce Work for Physicians. Changing the Documentation Philosophy from "Bigger is Better" to "Short But Sweet" Can Reduce the Documentation Burden, Streamline the Writing and Reading of Clinical Notes, and Enhance their Utility for Medical Decision-Making, Patient Education, Medical Education, and Clinical Research. We Believe that These Changes Can Favorably Affect Physician Well-Being Without Adversely Affecting Reimbursement.




National Institutes of Health, Grant UL1TR002003

Keywords and Phrases

clinician well-being; documentation burden; electronic health records; evaluation and management coding; medical decision-making

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Article - Journal

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Final Version

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Publication Date

28 Nov 2022

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Chemistry Commons