When documenting an encounter or referral letter in an EHR, the notes can range from scanty to very comprehensive. Some clinicians take great pride in their note-keeping and the ability to generate a well-written referral. Just as note-taking in paper charts can vary in terms of quality and accuracy, the same can be said for electronic health records. However, the design of the EHR is a critical determinant when data is presented in reports, letters, or referrals.
A recent comment submitted by an EHR user reflects this challenge:
“Although my EHR meets all of the standard criteria, the output does not look professional in that it appears that all we are doing is the necessary documentation for each patient. The output is not something I am proud to send to my consulting physicians because of this fact.”
EHRs can be divided into two broad categories:
- EHRs that collect the majority of the encounter data in discrete format using menus, drop-down lists, check-boxes, and templates.
- EHRs that collect the majority of encounter data using text in a free form or narrative format using a single large text box or multiple text boxes.
This is not entirely accurate, as there are EHRs that combine the best of both of these options, requiring some data to be collected in discrete format and other data in narrative format. But the way data is predominantly collected influences the output of the data in reports and letters.
Clinicians need to understand the story of the clinical problem. The standard SOAP note used during a clinical encounter has been designed to collect and present the most relevant information in a format that makes it easy for others to quickly understand the logic behind the treatment and diagnostic decisions. However, if an EHR is not able to present a narrative story in the referral letters or consultant reports, it can become a jumble of information that then becomes difficult to understand and draw reasonable conclusions from. It may take longer for a consulting physician to unravel the history and prior investigations — a somewhat self defeating result of an EHR, which is intended to make the sharing of information easier.
For example, if an EHR is designed to collect information in a very structured format, it can be difficult to construct a document that makes intelligible sense with notes that read like a series of bullet points. This problem can be solved by creating referral templates that include clear narrative descriptions into which the discrete data is embedded. Similarly, EHRs that collect and present predominantly narrative notes may produce better looking referral letters, but may have difficulty integrating discrete data.
The bottom line is that whatever EHR you are using, you should carefully review the types of referral letters or consultation reports that are produced to ensure that they meet your needs or can be customized to fit your documentation style. This is often ignored.
Are you proud of your EHR documentation? Share your experiences by adding a comment.