Will the final rule change how doctors are documented?

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I wondered: will the final rule of the 21st Century Care Act change how doctors document themselves? Recently Skeptical Scalpel (surgeon, writer and senior member of the Twitter intellectuals) shared the experience of a family member who was concerned about his cervical MRI report:

My 38-year-old non-medical daughter just received the MRI results of the cervical spine online. She was worried about biapical scars. I assured him that the radiologist had just been complete.

(As a background, the launch of reports to patients are part of a new one Law called the 21st century takes care of the rule of interoperability and blocking of information. It starts in action this week. Read more at the link. And from here I will call it the “final rule.”)

In response to the skeptical scalpel, Penn’s radiologist, Dr. Surabh Jha, wondered if this was the case. a problem of patients seeing their reports or a problem with the documentation we grew up with:

To be clear, the problem with reporting clinically irrelevant incidental findings is not just that patients read the report and may be concerned. Is that why you report irrelevant things in the first place? (apart from proving your mastery of anatomy)

I remember at first it was suggested that the Care Rule would not change the way doctors document themselves. We would continue to do what we have always done.

The final rule will change the way health professionals are documented

I suspect we will not continue to do what we have always done. And over time, the final rule will change the way doctors document themselves. I’m not judging if that’s the case well or bad.

This brief Twitter exchange reflects the kind of conversations that are beginning to take place about the transparency of medical records. The final rule will force us to face some of the things we have always done.

As an example, I’ve been struggling with how I use the term anorexia in my chart:

I use the term anorexia all the time to describe loss of appetite in children and babies. I it almost always causes confusion. Then I have to explain the difference between a symptom and a neuropsychiatric diagnosis. Every time I do this I think I should probably stop doing. Because the effort to explain the difference is not worth the time to try to correct.

So here’s a question: Were the first champions of open notes correct when they said they shouldn’t change the way they document? Absolutely. Will I continue to argue with patients for an obviously confusing word? Absolutely not.

It is the difference between what is required of us and what we will do. And for this and other examples I have begun to change the way I document myself.

We never know how a technology will impact society

Greater transparency and patient agency will be part of the healthcare fabric in the future. And the best we can do professionally is to openly discuss the changing purpose of medical documentation in the context of this cultural change. As a profession in redefinition, collaborating with our patients on this mission is an excellent way for physicians to define themselves.

Joi Ito suggested Whiplash, The truth is that a technology means nothing, in itself … What technology really does, the real impact it will have on society, is often what we least expect.

No one can predict how the open note experiment will turn out. But health professionals and their patients are in a good position to help us set up and guide our direction.

And creating the future instead of guessing where it can take us is the best approach.


If you like It will change the final rule in which doctors document, you can consult other publications of the Care rule. You can find them at Final Rule Archive. Each post here has tags at the bottom that will help you navigate the site to read related ones. He EHR file it is also interesting.

Image: William Osler writing at Johns Hopkins Hospital



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