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The Future of Documentation

There are several trends to consider in terms of the future of documentation.

First, it is important to consider the role of the client in documentation. There is still a lingering sense among some healthcare providers that clients shouldn’t be permitted to view their own personal health information. This is rooted in a legacy of paternalism, whereby healthcare providers were once deemed the sole authority on health. As we shift toward a client-centred approach, where clients are treated as experts on their own health, it makes sense for healthcare providers to acknowledge that clients own their own health data. Indeed, the development of new technologies has given rise to personal health records (PHRs), which are patient-held and patient-owned versions of health records that contain much of the same information as EHRs. Countries with established and robust national EHR are also moving toward facilitating clients’ open access to these records.

Another element to consider in moving forward is data literacy for clients. In this context, data literacy refers to a person’s ability to read and understand relevant healthcare-related information. This is becoming more important because clients increasingly want access to their health records, and many hospital institutions and laboratory testing services now provide a direct portal for clients to access their own information. Therefore, it is important that data are recorded in ways that can be easily interpreted by clients and/or that healthcare providers are trained and prepared to help clients understand the data.

It is reasonable to expect that most health systems and organizations will move towards EHR documentation primarily or exclusively. This increasing shift toward documentation in EHRs has important implications for documentation practices and care provision among nurses.

  • Nurses will need flexibility and adaptability to be able to learn and effectively use different EHR systems that may vary across different practice settings whilst concurrently ensuring high quality and consistent documentation practices.
  • Nurses will need to be able to navigate and use EHRs in ways other than documentation. For example, they may need to interpret EHR dashboards, which are summaries of real-time individual client information that are displayed on the main page of an EHR.
  • EHRs are becoming more sophisticated, and artificial intelligence is being used to support data-driven clinical decision making. Basically, this means that data documented in the EHR can be used to build algorithms to predict aspects of clinical care or client outcomes (e.g., risk). These predictions are then used within the EHR to provide warnings, alerts, or guidance for healthcare providers to inform the provision of care. The quality of artificial intelligence systems relies primarily on the quality of documentation within the EHR, so the importance of ensuring accurate, complete, and consistent documentation cannot be overemphasized.

 

Points of Consideration 

Artificial Intelligence 

As a healthcare provider, you should be aware of the biases inherent to artificial intelligence (AI) (Canadian Medical Protective Association [CMPA], n.d.b). Programs are designed by individuals who all have inherent biases. If a program is created with a bias, the bias will be systematized into the algorithm. Therefore, AI should be considered a clinical aid to supplement, and should not replace your own clinical judgment (CMPA, n.d.b).

 

License

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Documentation in Nursing: 1st Canadian edition by Jennifer Lapum, Oona St-Amant, Charlene Ronquillo, Michelle Hughes, and Joy Garmaise-Yee is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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