Clinicians and The Modern EHR: Statistician, Scribe or Storyteller?

Authors

DOI:

https://doi.org/10.3823/1601

Abstract

The Health Information Technology for Economic and Clinical Health (HITECH) Act spearheaded the rapid adoption of electronic health records (EHR) in the United States. Although HITECH's mission is to implement data storage, order management, evidence-based decision support, electronic communication and connectivity, and administrative processes and reporting (i.e. billing and coding), the main purpose of the EHR for the practicing clinicians should remain the same -- to convey the story, facts, and plan for the patient’s health care to the reader. We define three categories of EHR notes: the statistical, the scribe, and the storyteller styles, the pros and cons of each, and how the strengths of each may be used for more effective written communication.

References

Committee on Data Standards for Patient Safety, Board on Health Care Services. Key Capabilities of an Electronic Health Record System. Washington, DC: National Academy of Sciences; 2003.

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Published

2015-01-12

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Section

Internal Medicine & Hospital Medicine