Forbes March 25, 2023
Sai Balasubramanian, M.D., J.D.

Among the many challenges that physicians face, one of the most cumbersome is clinical documentation. In a study published by the Journal of Graduate Medical Education, it was found that nearly 92% of physicians surveyed reported that “documentation obligations are excessive,” and 73% reported that clinical documentation often has a negative impact on patient care.

The goal behind detailed clinical documentation is to ultimately ensure great record keeping: in an ideal world, a comprehensive patient chart enables any treating provider to see a patient’s entire medical and treatment history. Furthermore, the healthcare system has been built in such a way that documentation plays a critical administrative role. Healthcare organizations use patient charts to code and bill for services provided. Documentation...

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