Leveraging systems thinking to design patient-centered clinical documentation systems

Adam S. Rothschild, Linda Dietrich, Marion J. Ball, Heidi Wurtz, Holly Farish-Hunt, Nhora Cortes-Comerer

Research output: Contribution to journalArticle

Abstract

A hospital is a type of system, yet healthcare information technology (IT) has largely failed to view it as such. The failure to view the hospital as a system has contributed to the practice of inefficient and ineffective clinical documentation. This paper seeks to address how current clinical documentation practices reflect and reinforce inefficiency and poor patient care. It also addresses how rethinking clinical documentation and IT together may improve the entire healthcare process by promoting a more integrated and patient-centered healthcare information paradigm. Rethinking IT in support of clinical documentation from a system-oriented perspective may help improve patient care and provider communication.

Original languageEnglish (US)
Pages (from-to)395-398
Number of pages4
JournalInternational Journal of Medical Informatics
Volume74
Issue number5
DOIs
StatePublished - Jun 1 2005

Keywords

  • Clinical documentation
  • Computerized patient record
  • Electronic health record
  • Nursing documentation
  • Problem-oriented medical record

ASJC Scopus subject areas

  • Health Informatics

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