Much of a physician's day is spent maintaining the patient health record.1–6 Not only has this negatively impacted job satisfaction for residents and attending physicians,7,8 but it also may be significantly reducing available time for patient care and negatively impacting patient outcomes.9,10 In a 2013 poll, 92% of residents reported that clinical documentation obligations are excessive, and 73% of residents reported compromises in patient care by these requirements.11 Among internal medicine residents surveyed in 2006, two-thirds reported spending more than 4?hours daily on documentation, while only one-third recounted spending this amount of time with patients themselves.1 For every 3?minutes spent face-to-face with a patient, 1?minute is needed for clerical tasks, with charting comprising the brunt of this work.3,12–14 These data are corroborated by a meta-analysis from 2010 that reported only 23% of a hospitalist's time is spent directly interacting with patients.15 One would think that advances in technology16 might reduce time committed to clinical documentation due to streamlining of data through an electronic health record (EHR); however, residents and attending physicians may be spending up to 3 times longer with the EHR than when they were using paper charting.17,18 The purpose of this perspective is to review the utility of the current practice of clinical documentation in US hospitals, assess areas of weakness, and discuss potential avenues for improvement.;Benefits and Weaknesses of Clinical Documentation Specific degrees of documentation are required by “Meaningful Use” regulations and act as incentives for physician compensation.19,20 It may seem obvious that the current health record has been developed to improve the quality of patient care, and it achieves this through various objectives. Only 2 of the major objectives of the documentation process are reviewed here as examples: (1) the improvement of interprovider communication, and (2) the prevention of medical error. These objectives were selected because they are 2 of the most commonly cited goals for medical data capture,21–23 and they also are high-priority targets for quality improvement, since the outcomes achieved can be quantitatively measured. Improvement of Interprovider Communication Anecdotally, medical documentation not only centralizes access to critical medical data, but also serves as a useful tool for information handoff during transitions of care. Unfortunately, whether due to constraints of having to rigorously and repeatedly document medical information or because of laxity, US providers are still not documenting clinical data accurately—thereby decreasing the utility of information being transferred.24,25 With increasing volumes of paperwork and redundancy in data capture, resident and staff physicians are also less likely to review clinical documents in their entirety,26,27 thereby increasing the risk of negligent behavior. Data are frequently automated via templates, which carries significant risk of inaccurate reporting due to falsely negative examination findings.28 Or worse, with the advent of the EHR, information can effortlessly be copied from prior charts, which could thereby perpetuate inaccurate data.29,30 According to a report of 167?000 Veterans Health Administration records, as many as 1 in 4 charts contain copied/pasted examination data, with medical students, interns, and residents responsible for the majority of these copied data.31;Targets for Intervention In order to optimize interprovider communication of health record data, efforts should be made to increase both the utility and accuracy of the data being communicated. While data utility is more of a subjective perception (eg, including echocardiographic data in a discharge summary that may not be particularly useful for the patient's dermatologist), accuracy is measurable and can therefore be targeted. The automation of data capture and documentation (eg, linking la
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