Healthcare Documentation: A Report on Information Capture and Report Generation

Medical Records Institute This report by the Medical Records Institute addresses the fundamental question of what information capture method(s) should be used to improve healthcare documentation, and provides a number of recommendations to the healthcare community. Extracts:

“Accurate, accessible, and shareable health information is a well-accepted prerequisite of good health care. Yet, the healthcare system in the United States continues to accept illegible handwriting and other documentation practices that diminish the quality of healthcare documentation through reduced accuracy, accessibility, and shareability…

…This report focuses on six documentation methods, i.e., handwriting, speech, direct computer input, document imaging, device capture, and clinical imaging, as well as their hybrids. The evolution from handwriting to electronic healthcare documentation is concurrent with a transition from free (i.e., unstructured and typically unsearchable) text to structured and interactive text. To better understand this transition, this Report addresses the characteristics of unstructured, structured, and interactive data capture styles.”

> Read full report abstracts


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