ICD10monitor January 30, 2023
Make your documentation tell a story that makes sense to the reader.
I have been talking about improving the electronic medical record and making it more end-user-friendly. Today, I am going to grouse about documentation in general.
My husband, who is a radiologist, and I were commiserating at how awful and uninformative provider documentation has become since we started practicing medicine in the 1980s. In the handwritten days, the story was better; it was just often illegible. But people didn’t waste copious chart real estate on useless rehashing of details which weren’t helpful even the first time they were introduced into the record.
I am going to share with you some of my biggest pet peeves and tell providers how...