Documenting for Colleagues

Like it or not, the move is on toward creating electronic medical record (EMR) systems that will provide histories of interdisciplinary and inter-provider care regarding a patient. This means that hospitals, therapists, physicians, and other providers will see what others have recorded regarding a patient's health care. It will be a major change that is going to affect you in the following ways:

1. There is the need to record information in standardized, universal documentation. This means less free text and more structured, interactive recording of specific data elements, eliminating ambiguity.

2. Any colleague may read your documentation and may question it. Be careful with every entry as the charts will be read beyond your practice.

3. You must protect the patient. Privacy concerns will require greater attention. Think of mental health issues. For example, just the recording of an admission into a mental health facility may do harm. Certain prescriptions allow others to reach a conclusion about a patient's status that you didn’t intend to reveal. Although this was always true, the problem is magnified when a whole medical community gets access to such information.

4. Under HIPAA, patients have a right to access their medical record or to get a copy of it. But for professional reasons, you may want to communicate something to your colleagues that you don’t want to be available to the patient. Such a message could be a simple code that warns, for instance, that the patient threatened twice to sue.

5. Even more difficult is the potential harm that may be done by recording a suspicion where you have no proof. It is one thing to write into your record that you have a suspicion of child abuse, just to remind yourself. It is quite another issue when such an unproven and potentially damaging entry is read by your colleagues. On the other hand, harm may be done if such an entry is not made when it is warranted. Making that distinction may not be easily accomplished.