Building Documentation Tools

Before building a template, ask: • Who documents, in which setting, how often? • What MUST be captured as discrete data (for reports, rules, billing, regulations)? • What existing tools can be reused? • What does the finished note need to look like for the reader (other clinicians, coders, patients reading open notes)? • How will we know it works (time, completeness, satisfaction)? Bring clinicians in early — show mockups, not finished build.