MedPage Today December 9, 2024
— The EHR has improved, but we still need better ways to document our exam, assessment, and plan
In the evolving world of healthcare, what should the medical record — and in particular, the 21st century progress note — actually look like?
Our notes have changed and adapted over the years, especially as we went from paper charts to the electronic health record.
The Perfect Pen
Many of us still remember those hours spent over paper charts, writing out in longhand the chief complaints, HPIs, past medical history, past surgical history, medications, family and social histories, allergies, review of systems, physical examination, assessment, and plan. Hours sitting in the nurses’ station or the residents’ work room late at night, finishing...
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