Documentation Is Fun, Just Like Me

While electronic medical records (EHRs) make our clinical documentation easier to read, and access, and find important information, EHRs allow more and more groups to expect that specific data elements be documented to collect, count, group, and analyze. And while such data collection and analysis is crucial to patient safety and quality improvement activities, and is often used for data research, we all spend more time documenting our charts than with our patients, which is universally frustrating, except for that one patient that none of us like spending any more time with because we seen them so often, but I digress. Let's dive into the importance of documentation for clinical communication, compliance, billing, and medicolegal aspects as well, while laughing at some of the abbreviations we all (should not) use.