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It’s time to change our documentation philosophy: writing better neurology notes without the burnout

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. Desp...

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Autores principales: Rodríguez-Fernández, Jorge M., Loeb, Jeffrey A., Hier, Daniel B.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Frontiers Media S.A. 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9742203/
https://www.ncbi.nlm.nih.gov/pubmed/36518562
http://dx.doi.org/10.3389/fdgth.2022.1063141
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author Rodríguez-Fernández, Jorge M.
Loeb, Jeffrey A.
Hier, Daniel B.
author_facet Rodríguez-Fernández, Jorge M.
Loeb, Jeffrey A.
Hier, Daniel B.
author_sort Rodríguez-Fernández, Jorge M.
collection PubMed
description 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.
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spelling pubmed-97422032022-12-13 It’s time to change our documentation philosophy: writing better neurology notes without the burnout Rodríguez-Fernández, Jorge M. Loeb, Jeffrey A. Hier, Daniel B. Front Digit Health Digital Health 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. Frontiers Media S.A. 2022-11-28 /pmc/articles/PMC9742203/ /pubmed/36518562 http://dx.doi.org/10.3389/fdgth.2022.1063141 Text en © 2022 Rodríguez-Fernández, Loeb and Hier. https://creativecommons.org/licenses/by/4.0/This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) (https://creativecommons.org/licenses/by/4.0/) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
spellingShingle Digital Health
Rodríguez-Fernández, Jorge M.
Loeb, Jeffrey A.
Hier, Daniel B.
It’s time to change our documentation philosophy: writing better neurology notes without the burnout
title It’s time to change our documentation philosophy: writing better neurology notes without the burnout
title_full It’s time to change our documentation philosophy: writing better neurology notes without the burnout
title_fullStr It’s time to change our documentation philosophy: writing better neurology notes without the burnout
title_full_unstemmed It’s time to change our documentation philosophy: writing better neurology notes without the burnout
title_short It’s time to change our documentation philosophy: writing better neurology notes without the burnout
title_sort it’s time to change our documentation philosophy: writing better neurology notes without the burnout
topic Digital Health
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9742203/
https://www.ncbi.nlm.nih.gov/pubmed/36518562
http://dx.doi.org/10.3389/fdgth.2022.1063141
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