Is There Such a Thing As Stand-Alone Clinical Documentation?

Imagine if every interested party in healthcare relied on one black and white document to determine a patient’s health care needs, insurance coverage, quality ratings and accreditation, or medical necessity for hospital admissions. This document would have to contain a large amount of information and it would probably end up being very cluttered. Our practices today require creating  an “abstract” of the record consisting of multiple documents and data sources or sometimes requestors want an entire record sent to them which could be hundreds or thousands of pages.

Until we get to the point of easily sharing interoperable data electronically through HIEs, we will continue to rely on release of information practices of fulfilling requests for records by pulling pertinent information from the chart. We find ourselves asking daily, “what is the minimum information we can send that will provide the most information?” We joke about how EHRs have actually increased the amount of paper used to print a chart because of formatting and “note bloat” from trying to cram too many things into each document. Could we ever get to the point of having just one patient summary document that can be shared across providers and levels of care?

I don’t think patient data and information can be summarized into one document in a chart nor should it be. If that were the case, medical records would consist of one source-document instead of the dozens of tabs and modules we have in the EHRs today. Due to the fact that opening up an entire chart to every authorized reviewer is not currently secure or feasible, we are still looking for information sharing solutions involving summarized documentation. That being said, the chart should have key data elements pointed to a destination document where the patient’s course of care would be summarized neatly in one place to prevent the author of the note from having to re-state information repeatedly. I do see some movement toward the single, stand alone document trend but I think there is still quite a bit of work to be done.

The continuity of care document (CCD) was created with the objective of standardizing a single document that could be sent to the next care provider. This document may also be referred to as the After Visit Summary or Discharge Instructions but CCD was coined by HL7 for Meaningful Use electronic exchange initiatives. This template intends to capture important elements from a patient’s clinical data including the problem list, history, vitals, and more pertinent information that would be helpful to the patient’s next provider.

So why does The Joint Commission (TJC) still require so many other documents in the chart if we are able to summarize the care well enough for the next provider with one document? With the focus of health IT professionals being on Meaningful Use and EHR optimization, I see a divide in objectives across departments within healthcare organizations because we are trying to please many different accrediting bodies or payers. I don’t believe there will be a time in the near future when everyone agrees on a standardized record set therefore documentation will continue to evolve with each requirement that comes along. In the meantime, we must ensure the minimum necessary information is shared for continuity of care in a concise and effective manner.

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About the author

Erin Head

Erin Head

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

1 Comment

  • I would propose a patient ‘data custodian’ model as a solution. The custodian, an agent of the patient and/or other stakeholders, performs duties of unifying patient data from various sources. The custodian then offers up queries to the data thru standardized API formats and per the patient’s privacy wishes. A free ‘viewer’ would give an authorized physician access to any and all parts of the patient’s ‘record’ that are allowed. This also solves the interoperability requirement.

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