title: Medical documentation: part of the solution, or part of the problem? A narrative review of the literature on the time spent on and value of medical documentation.
abstract: BACKGROUND
  Even though it takes up such a large part of all clinicians' working day the medical literature on documentation and its value is sparse.
  
  
  METHODS
  Medline searches combining the terms medical records, documentation, time, and value or efficacy or benefit yielded only 147 articles. This review is based on the relevant articles selected from this search and additional studies gathered from the personal experience of the authors and their colleagues.
  
  
  RESULTS
  Documentation now occupies a quarter to half of doctors' time yet much of the information collected is of dubious or unproven value. Most medical records departments still use the traditional paper chart, and there is considerable debate on the benefits of electronic medical records (EMRs). Although EMRs contains a lot more information than a paper record clinicians do not find it easy to getting useful information out of them. Unlike the paper chart narrative is difficult to enter into most EMRs so that they do not adequately communicate the patient's "story" to clinicians. Recent innovations have the potential to address these issues.
  
  
  CONCLUSIONS
  Although documentation is widespread throughout the health care industry there has been almost no formal research into its value, on how to enhance its value, or on whether the time spent on it has negative effects on patient care.
authors.affiliation: Dundalk Institute of Technology, Dundalk, Ireland.
authors.forename: Neil
authors.initials: N
authors.lastname: Clynch
authors.affiliation: Thunder Bay Regional Health Sciences Center, Thunder Bay, ON, Canada. Electronic address: jgkellett@eircom.net.
authors.forename: John
authors.initials: J
authors.lastname: Kellett
mesh_terms: D004282:Documentation; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data* / Q000600:supply & distribution* / Q000639:trends; D005791:Patient Care; D010820:Physicians; D013997:Time Factors
keywords: Electronic medical records; Medical documentation; Medical records; Quality of care