Institute: ONC | Component: 2 | Unit: 4 | Lecture: e | Slide: 10
Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Processes and Decision Making
Lecture:Making a diagnosis Choosing therapy Communicating the plan The impact of EHRs and technology on clinical decision-making
Slide content:Oneself Nothing clears up a case so much as stating it to another person (Sherlock Holmes, fictional character of Sir Arthur Conan Doyle, 1893) Processing effect of recording case Effect of structure and order Impact of recording technology Prospective memorynotes to myself, a la memento 10
Slide notes:A less obvious person with whom the clinician must communicate is himself or herself. As Sherlock Holmes said, Nothing clears up a case so much as stating it to another person; this comment refers to the cognitive processing that occurs as we organize and articulate information. Even if the clinician doesnt verbally explain the case to another person, he or she understands the case better by creating a written or documented record. Cognition is aided by imposing structure and order, and may also be impacted in some way by the methods and technology used in the documentation process, such as dictating, writing, typing, or using macros and smart text. Creating clinical notes not only aids the clinicians processing of the case, but its also a means of communicating with himself or herself in the future as well as sharing valuable patient information with other clinicians and caregivers. Todays note, if well written, becomes an excellent basis for reestablishing the state of affairs at the next patient encounter, which may be many months or even years away. 10