Legibility

EHR Legibility — Can You Read Your Notes Two Weeks Later?

The following comment was submitted by a physician because of his inability to interpret his own notes a few weeks after entering encounter information into his EHR. His experience questions the value of discrete data (such as pick lists, radio buttons, numeric values, or predefined descriptions) vs. free text or narrative notes.

“All of the EHR systems we looked at and that other medical groups have used in our community are complicated, verbose and confusing. They ALL require far more time to use than dictating a note. They provide no more information than the records we are already using. An EHR note may be 5 pages long whereas a dictated note will be 2 pages long, succinct and far more intelligible than an EHR. I cannot easily read one of my own EHRs after a few weeks.”

If this doctor’s experience mirrors that of other users of EHRs, there is still a significant gap between the intelligibility of the EHR note that is “assembled” from discrete data vs. the traditional narrative note that tells the patient’s story. The narrative note is one that clinicians are more comfortable with, particularly in patients with complex co-morbid conditions. It is extremely difficult to document the chronology of illness progression using just discrete data.

Does your EHR allow you to tell your patient’s story? Can you return after weeks or months and clearly understand what you have previously entered into the system? If so, what do you consider the most important aspects of clinical documentation?

Comments:

2 responses to "EHR Legibility — Can You Read Your Notes Two Weeks Later?"
  • May 29, 2012
    Robert D. Lafsky M.D.
    said:

    25 years from now the HPI element of the record will be in narrative text form 100% of the time, and people will laugh at the absurd input systems from this period the way we laugh at giant cell phones now. Sophisticated software will extract the useful granular data from the text when necessary for analytic purposes, but the actual caregiver will have an actual narrative record for actual care of the actual patient.

  • June 13, 2012
    Fred Kelsey
    said:

    I agree the EHR as they are now used have degraded the function of the medical record as a vehicle of recording the patient’s story and medical care. What were 1-2 page narratives that followed a logical sequence now have morphed into long disjointed and sterile document. We have gone from extensive pick lists back to a typed narrative for the history and left only elements that need directed entry to the pick lists. We found that any pick list of symptoms/findings never follow a medically logical sequence that we all use when taking a history. The order and bundling of symptoms/findings are different for each patient and the problems presented. They are not amenable to alphabetical order! I find reading an old note in narrative form really allows you to “feel and understand” what you or the other clinician was thinking and is much more efficient.

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