I remember in my training as a medical student, one day as I obsessively wrote down and documented (to a degree that would probably be required today), a wise resident pulled me aside and asked, “What is the name of this section in the chart?”
Explore This IssueAugust 2008
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“It is the progress note section,” I responded.
“Well, do not put anything in there unless there is progress,” the resident said.
I suspect if Dr. Stead were alive today he might modify his famous saying to, “What this patient needs is a doctor—not a document.”
Jeffrey W. Wilson, MD, MBA
Lynchburg Rheumatology Clinic,