The Electronic Patient Record: A Practicing Physician’s Perspective

Medical Issues

The quality of medical decision making in general is dependent on (1) access to the available information, (2) the quality of the information, and (3) the quantity of relevant information. In any given medical note, specific physicians will want specific information. Thus, optimization of the signal (relevant information) to noise (irrelevant information) is a necessary property of structured notes. Simply because someone (usually not a person who is ever going to try to wade through one of these notes) thinks every item of information available for that day should be included, does not mean that is a good idea. The use of hyperlinks to laboratory and radiographic reports for example would be vastly preferable to automatic inclusion of the text in every single progress note by every service.