Articles, HDM December 21, 2016

Reconsider Documentation Vision for EHRs

by Barry P Chaiken, MD

Remember the blue book? Starting as early as junior high school, teachers handed out that pale blue 8” x 8” booklet when each student had 50 minutes to handwrite as fast as possible everything they knew about a particular subject. Urban legend suggested teachers issued grade based upon the number of pages filled rather than the content inherent in the illegible scribble.

The introduction of EMRs over the past decade completely changed the way we write clinical notes. No longer limited by our hand driven writing speed, our notes reflect typing speed, and more importantly the functionality of the EMR used for documenting care.

Although a more detailed note provides better clarity of the medical condition of a patient, patients do not have just one clinical note in their medical record. Every clinician – physician, specialist, nurse, therapist, resident – write notes. Inevitably, note writers record similar patient findings and lab values, copy text from documentation already contained in the medical record, and detail assessments and plans already recorded.

Blaise Pascal, a French mathematician, logician, physicist, and theologian wrote in 1656:

Je n’ai fait celle-ci plus longue que parce que je n’ai pas eu le loisir de la faire plus courte.’ or roughly translated as ‘I have done it longer because I did not have the leisure to make it shorter.

As all clinicians are pressed for time, they utilize the fastest means possible to complete their note with the most information. Like Pascal, they do not have the time to succinctly formulate the note and remove less important or distracting patient data documented elsewhere, but rather make it “plus longue” rather than “plus corte”.

Excerpts from: Why It’s Time to Reconsider a Documentation Vision for EHRs. Health Data Management, December 15, 2016

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