Time Spent on Clinical Documentation

Abstract

Clinical documentation and clerical duties required to process patient care are substantial activities for internal medicine residents, with trends showing an increase in the amount of time spent performing these activities over the past 2 decades.^1-4 Duty hours for residents are receiving increased attention, and the activities that occupy resident time when on duty are under scrutiny. The Accreditation Council for Graduate Medical Education (ACGME) instituted work-hour restrictions in 2003 to decrease fatigue-related medical errors.⁵ The report released by the Institute of Medicine in 2008 not only reiterates recommendations for duty-hour restrictions but also recommends that activities with limited or no educational benefit be minimized and time for patient care and self-reflection be emphasized to preserve the educational experience.⁶