Medical Documentation in the Electronic Era

Abstract

PATIENT-CENTERED CARE (PCC) HAS BEEN EMBRACED by many professional societies. For example, it has been included by the Institute of Medicine as 1 of the 6 goals of quality improvement. One aspect of PCC that is being increasingly considered is allowing patients greater access to their medical records. However, the adoption of personalized health records (PHRs) has been modest at best. There are many challenges to be addressed in PHRs, including the bidirectional flow of data from the PHRs kept by patients to the electronic medical records kept by health care institutions. Access to personal health information has the potential to transform the delivery of PCC. However, clinicians today continue to learn and use medical jargon that patients cannot understand, limiting the use of these new communication tools for patients and families. Medical jargon should be replaced with everyday language in clinical documentation to promote efficient communication and PCC. Eliminating jargon from medical records also may help patients participate actively in their own care. Language also has implications for medical training. Today, medical students starting clerkship rotations may need to consult Wikipedia or other sources to translate the medical jargon and acronyms contained in a patient’s medical record. Medical language can be confusing for medical trainees as well as for practicing clinicians because acronyms and jargon often mean different things in different specialties and contexts. Unless the meaning of acronyms and medical abbreviations is clear, use of these shortcuts could contribute to medical errors and delays in care. However, practitioners continue to use acronyms because of convenience and time constraints. Furthermore, many medical terms are difficult to pronounce and spell and take time to learn. These include anatomical terms as well as drug names. Frequently, medical trainees are encouraged to use generic drug names rather than brand names. However, generic names can be difficult to pronounce or remember because they are often based on names of chemical compounds. For example, few medical trainees will know the name of the monoclonal antibody for respiratory syncytial virus palivizumab; instead, most will remember the brand name Synagis. Perhaps, medical practitioners should learn from the marketers or should require pharmaceutical companies to provide generic names that are easier to remember for both patients and clinicians. This way, patients also might be more likely to remember the medications they are taking. Medical trainees initially spend time learning medical jargon, but often have to “back-translate” medical terms into simplified language when they communicate with patients and families. For example, in the traditional brief presentation during medical rounds, trainees are expected to use scholarly jargon to demonstrate knowledge and convey information about the patient concisely. Yet when they return to the wards to discuss treatment options with the patient, they have to use terms that are easy to understand. This process of learning and unlearning, or “backtranslating,” can be inefficient and confusing for the learners and can create communication gaps with patients if the back-translation is not performed well. Using the same language is an important first step in shared decision making between patients and clinicians. For example, myocardial infarction could be noted in a patient’s record as heart attack. Although some physicians may see this simplified language as demeaning to the profession, it can enhance communication between patients and clinicians and facilitate bidirectional flow of data and PCC. What should be done for the future of medical documentation? Documentation should be based on the reader’s experience rather than the writer’s perspective, because the primary purpose of documentation is to communicate information to another party. Three suggestions may help to achieve a better reader experience in medical documentation