テクノロジーによる記録の書き換え：臨床文書の進化と未来

This article traces the historical evolution and current complexities of clinical documentation, emphasizing its transformation under regulatory, financial, and technological influences. It explores how documentation practices-shaped by stakeholders like Centers for Medicare and Medicaid Services, insurers, and legal systems-affect clinical workflows and provider burden. The article identifies major challenges, such as note bloat, inefficiency, and burnout, and reviews innovative solutions, including artificial intelligence-enhanced tools and design changes in electronic health records. It calls for stakeholder collaboration and evidence-based reform to make documentation more meaningful, efficient, and supportive of clinician well-being.