• Rade B Vukmir.
• Drexel University, United States. Electronic address: rbvmd@comcast.net.
• Med Clin (Barc). 2024 Apr 26; 162 (8): e9e14e9-e14.

IntroductionThe busiest times in the hospital are often met by the greatest challenges in complete and comprehensive documentation of the patient care event. The near complete transition to the Electronic Health Record (EHR) was to be the solution to a host of provider documentation concerns. It is clear the EHR provides reliability, reproducibility, integration, evidence based decision-making, multidisciplinary contribution across the entire healthcare spectrum.MethodsThe use of a consensus of expert opinion supplemented by focused literature review allows a balanced evidence based presentation of data.ResultsDocumentation is not a perfect tool however, as issues with efficiency, reliability, use of shortcut maneuvers and potential for increased medico-legal risk have been raised. The solution is attention to documentation detail, and creation of systems that facilitate excellence. The focus on electronic documentation systems should include continual evaluation, ongoing improvement, involvement of a multidisciplinary patient care team and vendor receptiveness to in EHR development and operations.ConclusionThe most effective use of the EHR as a risk management tool requires documentation knowledge, targeted analysis, product improvement and co-development of clinical-commercial resource.Copyright © 2024 The Author. Published by Elsevier España, S.L.U. All rights reserved.

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