The elements of a good encounter note:
For those who are not in medicine or medico-legal disciplines, let me describe the clinical enocunter note. A patient arrives in the clinic or emergency room, with a complaint or complaints, and the physician asks a more-or-less directed series of questions, perhaps orders some tests, draws some conclusions and scribbles some summary notes. The resultant document is designed to be structured as an argument in support of a set of conclusions, resulting in a plan of action. A good note has the following characteristics: it is complete, coherent, and logically sound. That way, if something unexpected arises in the patient's condition, it is easy to understand why the physician decided on the course of action, and possible to compare what she did with what other similarly trained clinicians might have done with the same information. Of course, acknowledging all of the small elements that support a clinical diagnosis and plan can be time-consuming, so there is usually some truncation in the name of efficiency. But in the era of a fully electronic medical record, the task is infinitely easier, since much of the entire experience of the clnician is traceable as she retrieves the data in support of her conclusion. If she summons an electrocardiogram (ECG) taken on her patient, the reference to that retrieval belongs in the chart, along with comparison ECGs from the same patient. The same is true of other laboratory results, images, and any other digital records that are pertinent. The chart can be a hyper-linked access log with annotations summarizing the decision points along the way. Other decision support tools can be embedded at the same time, including treatment guidelines and reference articles. Much of this can be automated, saving the clinician time while creating a very robust document. The potential drawback of this kind of solution is that the parts of the chart that are left out may be quite important but harder to document; nuances, intuition, and the art of observation are harder to describe verbally, but may be very crucial. I would still argue that this kind of chart would be an improvement.