In my previous blog I ranted about the diminishing value of the encounter note. Specifically, I lamented (cynically) the inclusion of superfluous exam elements and long-winded template generated verbiage that obfuscated the true exchange of information.
For twenty years I practiced on paper. I dictated every note. I dictated in front of each patient which served in many ways. First, it assured the patient that I was indeed listening to their complaint. Second, it assured accuracy, as the patient could correct any element that I misspoke or misunderstood. Third, I dictated in lay terms allowing a patient to hear my impression, plan and instructions making it certain that we were “on the same page.” Lastly, it was time efficient and honest.
My method of documentation is “so yesterday.” My “quality” transcriptions were not mineable. They did not contain discrete codified data that could be used for treatment algorisms, decision support, alerts, research, or public health monitoring. With the emergence of the EMR my style of documentation can no longer stand alone.
Betty Rabinowitz, M.D. in a recent case history in Healthcare Management Technology chronicled the evolution of a “hybrid” note used at the University Of Rochester School Of Medicine. They combined a templated mineable encounter note with a speech recognition narrative. This approach seems to provide the best of both worlds. Like so many great ideas in our profession, the implementation (cost, software limitations, training and acceptance) becomes the hurdle. The experience in Rochester gives me hope that the inevitable return to a quality exchange of information is clinically achievable and underway and that concise narratives can continue to serve a purpose in the new world of the note modules.
Everybody gets so much information all day long that they lose their common sense.
Gertrude Stein (1874-1946)
