An analysis of both versions of HPI note of a patient
An analysis of both versions of HPI note of a patient, first a narration by a physician based upon which it was documented by the transcriber and the second which was documented using an EHR point-and-click template will indicate the difference, for example:
#1 HPI Note - Dictation and Transcription based: The patient is an 83 year old male who is reported to have tripped and fallen; the 83 year old male has complaints of pain in the neck with a severe headache. The patient states that he tripped and fell in the shower and was immobilized for a couple of minutes, with intense pain in the neck and shoulder. He is unable to recollect the time of the fall, but is certain that he was conscious, the patient is also complaining of shortness of breath.
#2 HPI Note - EHR Template based: Location of accident: Shower Time of injury: Not specifically known. Description of fall: Tripped. Severity of pain: Acute. Location of the pain: Neck & Head. Secondary Complaints: Shortness of breath Laceration or bleeding: None. Intoxication: No trace of alcohol. Mitigating factor: Negative
Amongst a host of physicians that were surveyed 97% preferred the dictation and transcription based HPI Note, the reasons stated for their preference was because of the uniqueness of the notes which addressed the issues that were specifically related to that particular patient, besides these notes had factors such as :
- The accurately worded reports safeguarded their clinics and their practice from legal liability.
- The notes captured the physician’s diagnosis that is unique and related to that patient only.
- The dictations and the transcripts allowed them an opportunity to easily recollect the personal information of the patient on subsequent visits.
- The narrative reports were easily understood by the patient, they were patient friendly.
Most of the physicians were of the opinion that their thoughts at the point-of treatment significantly contributed to high quality care of the patients. The EHR templates were structured and the resultant documentations will be difficult to differentiate one patient from another. The majority of the physicians required the Department of HHS to ensure that the electronic patient notes are not limited to template text or structured data only.
In spite of features available in the template for entering additional information, the physicians felt that they will be additionally burdened and documentations will get delayed, the narrations are quicker and simpler, requiring no documenting or typing inputs from them. The conclusion drawn from the forums was that point and click templates will serve limited objectives, the process of dictation and transcriptions cannot be ignored at any cost.
