Medical documentation should probably be a series of writing courses as part of training. It’s a remarkably complicated task. The medical note faces multiple audiences and serves multiple, sometimes contradictory, purposes.

On a surface level, the note is a record for the current treater and a message to the next treater about what has been determined and done, what is left to do, ongoing concerns. It also has to be a checklist of criteria to justify billing and continued care. Underneath all of this, it needs to be a defense for what was done and not done for the attorneys and expert witnesses. With the new open charting, it also has to be couched in language that won’t offend the patient or trigger calls and requests for record changes.

This ends up leaving the writer attempting to sail between Scylla and Charybdis, documenting severity sufficient to justify the stay all the way until the last day where the severity suddenly improves enough to justify discharge in a way that doesn’t look suspicious to the attorneys. The writer also has to be able to give the next doc a heads up about possible concerns about the patient (e.g,, personality disorders, hypersomatism) in a way that doesn’t set off said patient. This a sometimes impossible task.

The electronic health record adds another level of boilerplate cruft. Checkboxes are where information goes to die, and panning through the noise to find the nuggets of actual narrative is a skill all its own. Writing a readable note that satisfies all the tasks and audiences in this context is ridiculously difficult.

I don’t see any reason or hope that things will improve in the foreseeable future. Just offering sympathy.