The impact of documentation burden on patient care and surgeon satisfaction

• Published in: Canadian Journal of Surgery Vol. 64; no. 4; pp. E457 - E458
• Main Authors: Ball, Chad G, McBeth, Paul B
• Format: Journal Article
• Language: English
• Published: Ottawa CMA Joule Inc 01-07-2021; CMA Impact, Inc
• Subjects: Analysis; Burnout; Continuity of care; Documentation; Electronic health records; Health care; Job satisfaction; Medical records; Methods; Paperwork (Office practice); Patient safety; Physicians; Practice; Psychological aspects; Surgeons; Systematic review; Canada; Calgary Alberta Canada
• ISSN: 0008-428X; 1488-2310
• DOI: 10.1503/cjs.013921

Unfortunately, these positive traits have also been seeded with unintended consequences, including prolonged surgeon work hours, frustration with repeatedly changing information systems, and a decrease in the time available to actually care for patients at the bedside. Examples include research (university ethics review boards and processes; provincial health care research impact assessments; individual program barriers and obstacles; grant agency applications), physician reimbursement (billing documentation; time stamp confirmations; fees submission; shadow-billing), teaching (competency-based education assessments; trainee evaluations), professional development (regulatory body performance, competency assessments and renewal exams; professional surveys) and quality improvement (introduction of new technologies, processes, pathways, checklists, safety protocols, and programs; safety learning incident reviews). Associate health care providers (nurse practitioners, physician assistants, clinical associates, surgical hospitalists) not only contribute to direct patient care, but also to documentation requirements. Within surgery, many high-volume ophthalmology outpatient practices employ dictation scribes, documentation specialists, billing (public and private) experts, and other clinical specialists (e.g., optometrists) to increase throughput, enhance efficiency, and focus the surgeon/physician on direct patient care.