Free Yourself from Free-Text Documentation
I still remember the opening words of a medical student's history and physical, which I encountered doing a chart review as a new registered dietitian:
"This unfortunate sole…"
Looking back, I can't tell if he was talking about the patient … or reviewing a restaurant!
As the rate of adoption of electronic records continues to climb, have we moved past inaccuracies — such as confusing "sole" (a fish) and "soul" (a person's spirit)? Or does eliminating free-text charting remove the "flavor" from the patient narrative?
Some prefer free-text documentation, thinking that it allows flexibility to describe complex situations and richer semantic meaning. But does free-text really mean freedom? In fact, for clinical nutrition managers, eliminating free-text means less time spent reading misspellings, syntax errors or overlong entries while doing chart reviews. Plus, you can make a stronger case that your department is contributing to quality measures and making diagnoses codes easier to capture for billing. So how can you help your staff free themselves from free-text?
Integrate, Don't Separate
Integrate your data with the rest of the documentation in the EMR and explore opportunities to use structured input to share your data. Can your documentation be pulled into other clinician's notes? Can the results of the RDN's interventions trigger alerts? Free-text narrative input doesn't lend itself to these uses.
Keep Your Audience in Mind
Other clinicians want to know your assessment. Using the nutrition care process and the mandated clinical terminologies of SNOMED CT and LOINC means that, ultimately, an RDN's analysis will be shared in the transition of care beyond the hospital walls.
Aggregate, Don't Dissipate
Beyond integrating our nutrition care process and terminology with the other health care teams at our facilities and systems, consider the health of populations. Big data requires a statistically significant amount of information, but it can drive evidence-based medicine. Yet, by some estimates, as much as 80 percent of the information remains unstructured.
Create, Don't Be Late
Drive a more thoughtful design of structured data input with your IT department. Some points to consider include:
- Form-Based Charting
Forms can include a combination of drop-down lists, checkboxes and free-text narrative boxes. The use of labels and medical record printing enhancements can improve the output.
- Flowsheet Charting
These time-stamp data, which helps tell the patient story in real time.
- Copy and Paste Can Be Controlled and Audited
If your staff often copies and pastes in free-text, think about why. Is it to describe a multi-factorial complex problem, or to save time?
Cathy Welsh Walsh, MS, RD, is a senior clinical analyst at St. Jude Children's Research Hospital. Follow her on Twitter.
(Photo: Ingram Publishing/Thinkstock)