Literature DB >> 27125861

The map is not the territory: medical records and 21st century practice.

Stephen A Martin1, Christine A Sinsky2.   

Abstract

Documentation of care is at risk of overtaking the delivery of care in terms of time, clinician focus, and perceived importance. The medical record as currently used for documentation contributes to increased cognitive workload, strained clinician-patient relationships, and burnout. We posit that a near verbatim transcript of the clinical encounter is neither feasible nor desirable, and that attempts to produce this exact recording are harmful to patients, clinicians, and the health system. In this Viewpoint, we focus on the alternative constructions of the medical record to bring them back to their primary purpose-to aid cognition, communicate, create a succinct account of care, and support longitudinal comprehensive care-thereby to support the building of relationships and medical decision making while decreasing workload.
Copyright © 2016 Elsevier Ltd. All rights reserved.

Entities:  

Mesh:

Year:  2016        PMID: 27125861     DOI: 10.1016/S0140-6736(16)00338-X

Source DB:  PubMed          Journal:  Lancet        ISSN: 0140-6736            Impact factor:   79.321


  17 in total

1.  Can Electronic Health Records Make Quality Measurement Fast and Easy?

Authors:  Eric E Adelman; James F Burke
Journal:  Circ Cardiovasc Qual Outcomes       Date:  2017-09

2.  Moving From Problem-Oriented to Goal-Directed Health Records.

Authors:  Zsolt J Nagykaldi; Huibert Tange; Jan De Maeseneer
Journal:  Ann Fam Med       Date:  2018-03       Impact factor: 5.166

3.  Time Requirements for Electronic Health Record Use in an Academic Ophthalmology Center.

Authors:  Sarah Read-Brown; Michelle R Hribar; Leah G Reznick; Lorinna H Lombardi; Mansi Parikh; Winston D Chamberlain; Steven T Bailey; Jessica B Wallace; Thomas R Yackel; Michael F Chiang
Journal:  JAMA Ophthalmol       Date:  2017-11-01       Impact factor: 7.389

Review 4.  Are We There Yet? Human Factors Knowledge and Health Information Technology - the Challenges of Implementation and Impact.

Authors:  P Turner; A Kushniruk; C Nohr
Journal:  Yearb Med Inform       Date:  2017-09-11

5.  Impact of Medicare Office Visit Payment Reform on Urologic Practices.

Authors:  Parth K Modi; Samuel R Kaufman; Megan V Caram; Chad Ellimoottil; Vahakn B Shahinian; Brent K Hollenbeck
Journal:  Urology       Date:  2019-01-22       Impact factor: 2.649

6.  Multitasking and Silent Electronic Health Record Use in Ambulatory Visits.

Authors:  Neda Ratanawongsa; George Y Matta; Courtney R Lyles; Christopher J Koenig; Jennifer L Barton; Kaylin Yu; Dean Schillinger
Journal:  JAMA Intern Med       Date:  2017-09-01       Impact factor: 21.873

7.  Organizational factors affecting physician well-being.

Authors:  Daniel S Tawfik; Jochen Profit; Sarah Webber; Tait D Shanafelt
Journal:  Curr Treat Options Pediatr       Date:  2019-02-09

8.  Rethinking What Is Essential in the Office Visit Note.

Authors:  Stephen D Persell; Heather L Heiman
Journal:  J Gen Intern Med       Date:  2021-05-23       Impact factor: 5.128

9.  Increasing the Capacity of Primary Care Through Enabling Technology.

Authors:  Heather M Young; Thomas S Nesbitt
Journal:  J Gen Intern Med       Date:  2017-02-27       Impact factor: 5.128

10.  Organizational Influences on Time Pressure Stressors and Potential Patient Consequences in Primary Care.

Authors:  Kathryn M McDonald; Hector P Rodriguez; Stephen M Shortell
Journal:  Med Care       Date:  2018-10       Impact factor: 2.983

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