With the introduction of EHRs, it became easier to write a long note than a short one. Use of copy/forward has contributed to significant errors in documentation, increasing the chances of poor communication with other members of the health care team and with patients. It also exposes clinicians to increased vulnerability from a medicolegal standpoint and to the risk of lower reimbursement and quality measures. But haphazard use of copy/forward is not the only reason documentation is often inconsistent and devoid of clinical synthesis, and teaching residents how to write good notes requires a holistic approach.
This webinar will review the role of clinical documentation and the current challenges to note-writing. Presenters will describe how to best frame — from the resident perspective and the program perspective — the benefits of high-quality notes. Participants will review a sample progress note and critique the note from a different viewpoint — clinical reasoning, synthesis of information, billing and medicolegal concerns, and patient-centeredness — and will recommend improvements to the note.
Presented by:Hussain Khawaja, MD Rebekah Gardner, MD Vidya Gopinath, MDDelaney Goulet, MD
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