Duly noted: UW–Madison iSchool’s Adam Rule studies the digital evolution of the doctor’s note

By Aaron R. Conklin, UW–Madison College of Letters & Science

Back in the day—the “day” being only about 10-15 years ago—when a patient went to visit a doctor, the doctor probably scribbled down handwritten notes to capture the essence of the appointment. Those notes were added to the patient file and used as a reference for future appointments.

The advent of electronic medical records, led by companies like Madison’s own Epic Systems, has transformed how doctor’s notes are written and, more broadly, the field of medical informatics. Today, doctors use several different documentation aids to help them create patient notes. They might cut and paste text electronically from a prior note, or they might use a tool within a records system to auto-populate a specific field. It is also likely they will use note templates, a popular tool that creates boilerplate text with placeholders for the doctor to input information specific to the patient.

While electronic medical records clearly have a long list of benefits—they’re legible, portable, shareable and can contain real-time alerts for physicians—the field is still growing and evolving, and some challenges have emerged along the way. Read more …