May 2016

Check Boxes, Lose Narrative
By Lee DeOrio
For The Record
Vol. 28 No. 5 P. 4

One of the basic tenets of journalism is to ask, "Why?" In general, it's a fail-safe method to elicit a meaningful answer from the interviewee: Why did you veto the bill? Why did you yank the starting pitcher when he was twirling a shutout? Why did the attorney general leak documents detrimental to a longtime opponent?

The same principle holds true for quality medical records: Why is the patient on this medication? Why is the patient constantly fatigued?

Does documenting in an EHR lend itself to this type of narrative? Most industry experts say there are severe limitations to the amount of detail that can be captured in an EHR. Instead of building a patient's story, this form of documentation reduces care to a series of lists with no context. In addition, pundits argue that EHR documentation is more focused on capturing data for billing purposes rather than patient care.

On recent occasions when I've had to visit a physician's office, there have been several times when I've explained a past treatment and then followed up with, "Don't you have that noted in my records?" The curious and rather frightening answer is typically along the lines of, "Well, it could be this … ."

"What gets lost in the cracks are those items that are not included in the menu of predesigned choices based on the patient's chief complaint for the clinician to click," says Brenda Hurley, CMT, AHDI-F, president of Hurley Makes It Happen! "A common example would be patients who present with more than one chief complaint. Drop-down menus were not designed for a patient with several equally significant problems to be addressed by the clinician. A narrative section would allow providers to cover these in a robust manner that will inform all of those involved in the care of that patient."

It's worrisome to learn that what I'm describing is not matching what was documented in the chart. Am I doing a poor job of explaining the encounter? Is the physician having difficulty translating my interpretation into medical jargon? Or did the physician pigeonhole the event into a tidy category when there were actually several facets involved?

"A physician should always, through the completeness of his or her documentation, explain the rationale—it's called 'think on ink,'" says Darice Grzybowski, MA, RHIA, FAHIMA, president of HIMentors, LLC. "In other words, if you place an order for a particular antibiotic, you should tell what your differential diagnosis is related to use of that. For example, 'Because of the gram-negative bacteria findings, we are prescribing X medication, because we believe it will resolve the pneumonia the patient is experiencing.'"

Unfortunately, one of my caregivers inexplicably chose not to exercise his storytelling prowess. Now, each time I visit my provider, I must weave my own tale. That can't be how an EHR is supposed to work.

edit@gvpub.com