Current problems with documentation

What's wrong with the current standard of documentation?

  1. The amount of text which is duplicated approaches 60%.
  2. Important Information is scattered throughout the chart.
  3. You are overloaded with information in the chart, hiding important details which are not clearly organized.
  4. 1 - 3 lead to Medical errors.

Many Assessment and Plans:

  1. Don't offer an actual assessment / diagnosis and are bloated with copy/forward text, much of which is inaccurate.
  2. These bloated copy / forwarded A&P's are more for you to have to sift through when you write your note.
  3. Copy / Forward mistakes make you look unorganized


Complete and Continue