Editor's Note: The Dangers of Medical Profiling
By Lee DeOrio
For The Record
Vol. 30 No. 7 P. 3
When it comes to documenting in medical records, perhaps it's best if physicians stick to Sergeant Joe Friday's advice: "All we want are the facts." Otherwise, preconceived notions and prejudices may seep into the record and follow the patient around like a 20-pound ID bracelet. These are the general findings of a Johns Hopkins study published in the May edition of the Journal of General Internal Medicine and spotlighted in this issue's cover story, "Choose Your Words Carefully," written by Lisa Eramo, MA.
A medical record is no place for flowery prose or inconsequential verbiage. According to the study, when physicians read notes and descriptions from previous medical visits, the language used may influence how they regard that patient, as well as how aggressively they manage the person's pain. In other words, treatment strategies can be shaped by documentation.
Eramo's article provides several examples of how this may occur. If you think about it, why should health care be different from any other supposedly neutral setting where language can frame a situation and inadvertently—or intentionally—influence the reader? For example, a police report that unnecessarily points out a person's attire or appearance can sway case strategy.
Are there guidelines at your organization regarding the use of nonessential language in medical records that implies various value judgments? For HIM professionals, spotting such situations and pointing them out can be dicey. Will a physician query suffice?
Regardless of the answers to those questions, those on the documentation front lines should be conscious of how chart notes influence not only coding but also patient care.
When it comes to recording patient encounters, experts recommend physicians use a tactful tone and the most objective language possible. Granted, physicians must keep in mind all those who will be viewing the chart, from billing and utilization review to insurers, quality assurance, and the patients themselves.
I'll be the first to admit that succinct writing is often the most difficult. As Mark Twain said, "I didn't have time to write you a short letter, so I wrote you a long one instead." Nevertheless, sticking to the pertinent details should not be an overwhelming task.
The Code of Ethics established by the Society of Professional Journalists—not always adhered to, especially nowadays—directs reporters to provide context, avoid stereotyping, and show compassion. It's a credo physicians would be wise to follow.