Current problems with documentation
What's wrong with the current standard of documentation?
- The amount of text which is duplicated approaches 60%.
- Important Information is scattered throughout the chart.
- You are overloaded with information in the chart, hiding important details which are not clearly organized.
- 1 - 3 lead to Medical errors.
Many Assessment and Plans:
- Don't offer an actual assessment / diagnosis and are bloated with copy/forward text, much of which is inaccurate.
- These bloated copy / forwarded A&P's are more for you to have to sift through when you write your note.
- Copy / Forward mistakes make you look unorganized