Picking up the thread of from last week's article, there are laws and regulations that specify what should be recorded in the medical record. There is a tendency to include irrelevant information while leaving out things that could be clinically useful.
Do experienced physicians have the experience and judgment necessary to decide what is important and chart only that? Probably, when the situation is unambiguous, but probably not, when the diagnosis is unclear. When I see patients in consultation — meaning that the diagnosis is unclear — it is rare that to find the information that I need already recorded in the chart. The situation is as it was in training, when something is not charted there is no way to tell why it wasn't charted. There is no reason to assume that any physician (including me) has recognized and appreciated some aspect of the patient unless it's included in the note.
In medicine, there are incentives to record as little as possible: personal style, time pressure, the effort of creating “long-winded” notes and systems that make it difficult or impossible to record complex information in a way that conveys the intended meaning. Some balance must be struck between terseness and detail but in the past, terseness has usually won out. When legislators and regulators are forced by circumstances to consider the question, they invariably decide that physicians do not provide enough detail. As a result there are now specific laws and regulations that impose documentation requirements, particularly in ambulatory care and long-term care settings. The Joint Commission on Accreditation of Healthcare Organizations imposes similar standards on what must be recorded in hospital charts.
The requirements relate to content and accessibility. They do not (for the most part) stipulate how the requirements are to be met; in fact they allow considerable flexibility. With the exception of certain specific situations, such as prescribing controlled substances, the degree of detail to be recorded in the chart is left to the judgment of the practitioner, with the law providing guidelines. These vary from state to state but California's are probably typical.
A striking dichotomy becomes apparent between two facets of medicine: initial diagnosis and general care on the one hand and specialized diagnosis and treatment, including the need for hospitalization and critical care, on the other.
There are compelling reasons (in certain situations to be discussed in a future article) to record great detail in the chart but it is neither required nor useful to include Information such as hourly I/O, q15 minute blood pressures or days of continuous EKG tracings on a hospitalized patient in the longitudinal medical record. Such information certainly must be recorded so that it is available to direct the course of care in the immediate future and it certainly must be retained as dictated by law, but that does not mean that is has to be part of the “chart.”
This modular (some would say fragmented) approach is actually desirable. There are good reasons to use specialized applications to insure that the best care is provided in ICUs, ORs, delivery rooms, etc. Furthermore, there is no reason that these specialized systems can't serve as repositories of the data that they collect (for the required retention period) provided that they send to the longitudinal record (the patient's chart) a summary of the significant events that transpired during a period of special care, the patient's condition when discharged, what unresolved or ongoing problems require continued attention, and what treatment is called for.
It appears that the optimal configuration for an EHR is one made up of a longitudinal record supplemented with “feeder systems” that help to manage patients with specific problems or needs and to deliver appropriate summaries to the longitudinal record at the time the patient is discharged from a specialized setting. As with the billing data mentioned last week, maintaining this separation makes it possible to purge this data at the appropriate time without disrupting the integrity of the longitudinal record.
This argues that patient care can be improved and the task of maintaining a useful long-term patient record can be simplified by using specialty systems rather than a monolithic EHR. It's better to employ discrete applications targeted at those patient care activities which generate large volumes of volatile data that, while important to patient care, will have little impact on the patient's subsequent care.
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