This position paper reviews the current and emerging purposes of clinical documentation, the drivers that may influence or distract from these purposes, and the opportunities and challenges that have arisen from EHRs. Although the term “EHR” is used throughout this paper, the issues addressed could reasonably apply to any future technology-enabled system of clinical documentation. Existing technology, such as registries, portals, connected home monitoring devices, and provider- and patient-controlled mobile devices, as well as technology not yet in use or even built, is likely to integrate with or possibly even replace the EHR (as currently conceptualized) as a primary vehicle for viewing and recording clinical documentation. Similarly, clinical documentation's definition has grown to encompass more than just physician notes. However, although “EHR” is the current term of art used to describe computer-based systems that perform a broad range of functions related to documenting and managing patient care, this will not always be the case. In the past decade, medical records have become increasingly synonymous with electronic health records (EHRs). The Medical Informatics Committee of the American College of Physicians has undertaken this review of clinical documentation in an effort to clarify the broad range of complex and interrelated issues surrounding clinical documentation and to suggest a path forward such that care and clinical documentation in the 21st century best serve the needs of patients and families. At the same time, many physicians and other health care professionals have argued that the quality of the systems being used for clinical documentation is inadequate. Although computers and EHRs can facilitate and even improve clinical documentation, their use can also add complexities new challenges and, in the eyes of some, an increase in inappropriate or even fraudulent documentation.

More recently, new information technologies, such as electronic health record (EHR) systems, have led to further changes in the clinical documentation process.

Over time, other stakeholders have placed additional requirements on the clinical documentation process for purposes other than direct care of the patient. Clinical documentation was developed to track a patient's condition and communicate the author's actions and thoughts to other members of the care team.

What is the purposes of medical records