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?