Dr. John Hickner, Editor and Chief of the Journal of Family Practice Discusses the Shortcomings of Many Medical Notes
In his recent editorial in the October edition of the Journal of Family Practice, Dr. John Hickner (MD, MSc) notes that many doctors fail to adequately document three portions of the medical note: history of present illness (HPI), assessment and plan.
"After reviewing many charts from several organizations, however,
I’m concerned that 3 important elements of documentation are getting
short shrift in our increasingly computerized and regulated environment:
the history of present illness, the assessment, and the plan."
Dr. Hickner was kind enough to chat with us at the American Academy of Family Practice Conference that ended yesterday. Like us, he wants medical notes to tell the story underlying the patient's present visit; not just a checklist of symptoms. The emphasis of quantity over quality by the healthcare system and electronic medical records (EMRs) has eroded the quality of the HPI. During our conversation at the conference, he acknowledged that scribes may have a role in solving the dearth of quality documentation by some medical doctors. You can read his full article on the Journal of Family Practice website. And again, it was a pleasure chatting with Dr. Hickner at the conference.
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