Reclaiming the Clinical Record to Support Patient Care
In a recent Ideas and Opinions piece entitled, Restoring the Story and Creating a Valuable Clinical Note in the Annals of Internal Medicine, Gantzer et al call for clinicians to, “…reclaim the clinical note as a means of showing the cognitive processing involved in turning medical information into a thoughtful assessment and plan.” They point out that, “There is a critical distinction between documentation and communication: Communication can document, but documentation alone rarely communicates what matters most.” They identify two…
