Bridging the Gap Between Decisions and Documentation

By Andrew Napier, MD FAAEM

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I’ll never forget one chaotic shift as a new attending. An elderly patient in septic shock rolled in first. Minutes later, multiple traumas from a highway pileup arrived, and not long after that, a cardiac arrest. Hours of relentless, life-saving decisions left no time for food, water, or even a deep breath. Yet when the shift finally ended, instead of heading home, I found myself staring at a computer screen, trying to piece together what I had done and why.

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What speed was the car traveling? What was the rationale for excluding that septic patient from 30cc/kg fluids? Why did I pick the left jugular for the central line instead of the right? My brain was fried, my body exhausted, and yet here I was, struggling to make sure my notes reflected the complexity of the shift and the care I had provided.

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That night stuck with me, not because of the chaos in the ED, but because of the disconnect I felt between the life-saving decisions I made in the moment and the sterile, checkbox-laden documentation I was expected to complete afterward. The tools we rely on to capture our medical decision making often feel woefully inadequate. They miss the depth of thought behind every decision and reduce complex care into something that feels flat, incomplete, and ultimately frustrating.

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What Makes a Good Clinical Note?

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Over the years, I’ve thought a lot about what clinical documentation should accomplish. At its core, a good note must do four things. It must (1) communicate clinical reasoning, (2) support billing, (3) create a defensible record of care, and (4) minimize the time burden on clinicians. When these goals are met, documentation becomes more than an administrative task. It becomes an extension of the care we provide.

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1. Communicating Clinical Reasoning

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Every note should tell the story of the patient’s care. It should provide the next clinician with a clear picture of what happened, what was done, and why. Research has shown that detailed, well-organized notes reduce errors, improve collaboration, and ultimately lead to better patient outcomes¹.

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Take, for example, a septic patient. The documentation needs to reflect more than the interventions performed. It should also capture the reasoning behind those interventions, why the patient didn’t receive the standard 30cc/kg fluid bolus, what risks were considered, and how the clinical picture guided each decision.

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This level of detail isn’t just about thoroughness. It is about preserving the patient’s story. A robust documentation system helps capture this complexity, not just listing what was done but why it was done. It supports collaboration, reduces errors during transitions of care, and ensures that the reasoning behind critical decisions doesn’t get lost in translation.

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2. Supporting Billing

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The 2023 AMA CPT updates have shifted the focus of billing documentation to medical decision making². This means that notes now need to reflect the complexity of cases, the risks involved, and the thought processes driving diagnostic and treatment decisions. Simply listing interventions is no longer sufficient.

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Consider a trauma case. To meet billing requirements, documentation must capture the interplay of injuries, the diagnostics pursued, and the risks managed. These notes are not just about justifying payment. They are about tying the complexity of care to its true value. A system that emphasizes depth and accuracy helps clinicians meet these standards without turning notes into a series of disjointed checkboxes.

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3. Creating a Defensible Record

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Clinical notes are not just for today. They form a lasting record of the care provided, which may be scrutinized in quality assessments, peer reviews, or even legal proceedings. A defensible record clearly explains the reasoning behind each decision, referencing guidelines and patient-specific factors³.

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Imagine treating a patient with mild head trauma. If imaging is withheld, the note needs to document why, outlining the thought process behind the decision and connecting it to clinical guidelines. Good documentation does not just reflect the care provided. It protects the clinician’s judgment and provides confidence that decisions were appropriate and evidence-based.

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4. Minimizing the Documentation Burden

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Even the best documentation systems fail if they demand too much time. Emergency departments illustrate this problem clearly. With an average of two patients per hour, a 10-hour shift might involve 20 patients. At 16 minutes per patient⁴, that adds up to over five hours spent charting, nearly half the shift.

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This time burden does not just sap energy. It compromises the quality of notes. A system that streamlines documentation while maintaining depth is essential. By integrating critical elements into a cohesive narrative, tools like Sayvant can help clinicians reclaim time without sacrificing the accuracy or completeness of their notes.

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Sayvant’s Perspective

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Sayvant exists to address these challenges for clinicians. Sayvant creates notes that meet all four goals of effective documentation – it massively streamlines the documentation process, but it’s built with a careful focus on depth and accuracy. 

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Sayvant integrates clinical decision-making frameworks, such as criteria for pulmonary embolism risk or guidelines for pediatric head trauma, directly into the documentation process. These frameworks aren’t just built into Sayvant to populate EMR fields. They reflect how those frameworks influenced your thinking and shaped your decisions.

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This same approach extends to procedure notes and critical care documentation. Instead of isolating these elements as standalone fields, Sayvant weaves them into the larger narrative of care. Details such as equipment used, steps taken, and complications managed are all captured. For critical care time, the focus is not just on the minutes logged but on the reasoning and interventions that justified that time.

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By embedding all these elements into one cohesive narrative, Sayvant ensures that your notes are comprehensive, reflective, and grounded in medical decision making.

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The Future of Medical Documentation

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Documentation should work for clinicians, not against them. It should support communication, reduce errors, and foster collaboration while preserving the continuity of care. At the same time, it must respect the time constraints of busy clinicians, allowing us to spend more time with our patients and less time at the computer.

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We did not train for over a decade to check boxes or fill out templates. We trained to make decisions, solve problems, and save lives. By addressing the documentation burden and improving the quality of notes, we can reclaim more of our time and focus on what matters most, the patient in front of us.

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References

1. Welch, S., et al. “Strategies for Improving Communication in the Emergency Department: Mediums and Messages in a Noisy Environment,” The Joint Commission Journal on Quality and Patient Safety, June 2013.
2. “MDM Determination in the ED,” AAPC Knowledge Center, July 1, 2023.
3. Amaniyan, S., et al. “Learning from Patient Safety Incidents in the Emergency Department: A Systematic Review,” The Journal of Emergency Medicine, 13 December 2019.
4. Fong, A., Hettinger, A.Z., & Ratwani, R.M. “Electronic Health Record Documentation Times Among Emergency Medicine Trainees,” Annals of Emergency Medicine, 73, 359–366 (2019).