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Daily patient notes have evolved from primarily a mechanism of communication among health care workers to a medical-legal document and a potential source of litigation to what it is now: a measure of physician time and effort. As awkward as it may seem, there is a relationship between the number of physical exam points or enumeration of problems and the amount of money that comes in from insurance reimbursements. In addition to addressing this important monetary issue, the Patient Notes Collaborative has been successful in fostering substantive communications between attending physicians and house staff. It has been successful in part by replacing repetitive dictations and independent annotations with a web-based application that coordinates resident and attending physicians´ efforts. The result is a single note per patient per day, typically comprised of objective data that are (or should be) observer independent (the "numbers"- vital signs, I/O´s, lab values) and subjective data that are observer dependent (interval events, physical exam, problem list with assessment plan).
The Patient Notes Collaborative is another database-backed web application developed utilizing the CTRL toolkit. By taking much of the repetitiveness out of a required task physicians and residents have embraced this system resulting in greater insurance reimbursements and better communication between physicians.
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