The risks of documentation

8394630603_05582283ec“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.”

– Stephen Martin and Christine Sinsky

Martin and Sinsky CA (2016). The map is not the territory: medical records and 21st century practice. The Lancet. doi:10.1016/S0140-6736(16)00338-X
photo credit: day 18/365 via photopin (license)

1 comment for “The risks of documentation

  1. Peggy Woodward
    May 30, 2016 at 9:00 am

    I have been saying this for decades. Haven’t read the full article yet as haven’t got access but I guess it’s focus is primarily on the demands on doctors. It’s horrendously difficult for midwives. The insistence on ‘contemporaneous recording’ seems to be accepted by my colleagues but I wonder how many we lose to the profession because of the ‘paperwork’ demands? I suspect it would have defeated me if I were 24 not 64.

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