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 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.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.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.

作者：Neil, Clynch；John, Kellett

来源：International journal of medical informatics 2015 年 84卷 4期