Documenting and Presenting Findings

Prose Versus Templated Entry

Two methods for entering data into the record are prose entry where the user types or uses speech recognition to enter the text and templated entry where a complex series of taps or clicks generates the entry. The latter is commonly used in acute care settings, such as emergency department and urgent care facilities, and in procedural areas where there are many standard aspects to documentation.

Templated entry is efficient, but some information and context are lost compared with prose entry. However, use of the template can reduce the chance that key elements will be missed, especially those that are part of required documentation. For example, the checklist before a procedure or thrombolytic administration needs to be standardized and complete to optimize patient safety.

For the history of present illness (HPI), prose entry is recommended. For many other elements of the neurologic history and examination, templated entry is acceptable.

Method of Entry

Common methods of data entry are typing, voice recognition, and scribe. Typing is essential for some portion of the entry, and this can be done in the presence of the patient and family. Voice recognition is widely used. It can be awkward in the presence of patient and family, especially when items with a negative connotation are entered, such as “morbid obesity,” a term that is specifically looked for when coding comorbid conditions.

Entry by the provider while they are looking at their screen has disadvantages for the encounter. The time looking at the screen results in loss of nonverbal communication. With the lack of sustained eye contact, the provider can miss observational components of the examination, including facial expression, spontaneous movements, and gestures. The computer becomes a barrier between the provider and patient, even if they are both looking at the screen; this is better than the alternative but is still suboptimal. Direct entry into the electronic health record (EHR) also results in the provider having less intellectual bandwidth to apply to the patient, having to wrestle with the user interface, making corrections, and having to look through the tabs of the chart during the discussion.

Scribes are in widespread use except in many academic medical centers. They can free the provider to be hands-on and to look at the patient. Some limited data indicate that quality of care may be enhanced by the addition of another teammate. In a multicenter study, scribes reduced emergency department length of stay and improved the number of patients seen by the provider per hour by 25.6%. A University of Chicago study in the primary care setting showed improved provider satisfaction, with more than 50% reduction in postclinic documentation time, with no decline in patient satisfaction; in fact there were some improvements.

Demographics and encounter details

Name, date of birth, and medical record number should be prominent; these elements should be on every page if the document is a PDF or is printed. Encounter details include date of encounter, institution, location, specialty, and provider.

Chief complaint

Chief complaint, or the reason for the encounter, is entered even if the patient is not able to express one. If the patient is able to communicate, then their impression of the reason for the encounter should be documented in addition to a reason that was indicated at the time of the encounter request, whether it was requested by the family, patient, or provider. Wording such as “here for neurology appointment” is not useful and should not be used. “Referred by Dr. X for Y problem, but the patient and daughter report they are here for Z problem” is a more appropriate documentation.