Electronic Health Records and the Importance of How to Document

Abstract

With the rise in use of information technologies—in particular, the development of data science—information is clearly more essential today than ever before in the management of patient care. However, these advances have not been paralleled by major changes in the general process of health documentation. Moreover, the primary clinical data generated during the care process is becoming increasingly relevant, and there are more and more actors/authors involved in the documentation process. Medical records long ago ceased to be an exclusively “medical” tool: they now involve the entire health team, including public health professionals. This has brought with it many challenges when responding to the different workflows in each discipline. In addition, there is a need to incorporate patient-generated data––whether automatic, from monitoring devices, wearables, etc.; or intentional, through information that patients generate personally, such as diaries, blogs, and questionnaires. [...]