Remember the blue book? Starting as early as junior high school, teachers handed out that pale blue 8” x 8” booklet when each student had 50 minutes to handwrite as fast as possible everything they knew about a particular subject. Urban legend suggested teachers issued grade based upon the number of pages filled rather than the content inherent in the illegible scribble.
Before healthcare information technology (HIT) and electronic medical records (EMR), clinicians wrote their notes similarly. Limited by the strength and stamina of their dominant hand, and their knowledge of the patient’s condition, clinical documentation represented a singular clinician’s assessment of the patient.
The introduction of EMRs over the past decade completely changed the way we write clinical notes. No longer limited by our hand driven writing speed, our notes reflect typing speed, and more importantly the functionality of the EMR used for documenting care.
Although a more detailed note provides better clarity of the medical condition of a patient, patients do not have just one clinical note in their medical record. Every clinician – physician, specialist, nurse, therapist, resident – write notes. Inevitably, note writers record similar patient findings and lab values, copy text from documentation already contained in the medical record, and detail assessments and plans already recorded.