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Spring 2022

Documentation Dilemmas: The Pros and Cons of Sharing Consultation Notes
By Reggie Ahlfield, MBA-HA, BSHI, RN-BC
For The Record
Vol. 34 No. 2 P. 5

One of the difficult decisions facing health care organizations in this time of rapid information is how much of it to share via the various EMR applications. There are ethical considerations regarding issues such as sensitive medical or mental health diagnoses, technical considerations surrounding the huge variety of EMR applications, and other more abstract implications to take into account.

The HITECH Act, part of the American Recovery and Reinvestment Act, was signed into law in 2009 by President Obama but can be traced back to the prior administration. The act created incentives for adopting electronic means of sending health information via EMRs and EHRs.

One of the initiative’s benefits was creating a platform to share medical records quickly and easily. For example, less than 15 years ago it was not uncommon for chart requests to entail a physician contacting the medical records department, which then would head to the archive to retrieve old charts. Even within the same health care organization, it was not uncommon for this task to take a day or two. The wait to receive a medical record from another state could take even longer—that’s if a provider was able to get it at all. In the meantime, patient care could be delayed—a situation that could have serious consequences.

Today, providers can simply change a date filter in whatever section of the chart they are reviewing and retrieve that historical information. It can even be done before the provider sees the patient, allowing them to begin formulating an appropriate diagnostic regimen to facilitate treatment much more quickly. Even technology-averse providers usually agree that this is a vast improvement over those days when delays were commonplace.

Ethical Challenges
Where the situation gets ethically challenging is, now that most records are electronic, it’s much easier to share their contents with patients. Most health care providers prefer that patients remain active and informed about their medical care and appreciate the ease that patient portals provide for doing so. However, most would agree that not everything health care professionals record would be of particular use to someone not trained medically.

For example, a progress note is used for a physician to follow a diagnostic path, and quite often that path changes based on the evidence. The emotional consequence it could have on a patient unfamiliar with this scientific process could be something as simple as reading a “rule-out” diagnosis and thinking they have something like cancer before there is enough evidence to support it.

Many health care providers have shared the story of how they were reporting on a patient being short of breath, which, in the medical field, is often abbreviated as “SOB.” But a layperson interprets this acronym as something entirely different.

Given that a provider has access to them prior to a patient, other documents seem more appropriate to share. For example, it is common for patients to view their lab work in the provider’s patient portal, then promptly search the internet to determine the data’s significance. For this reason, many institutions will place a 24- or 48-hour delay on posting these results to the patient portal. This gives physicians the opportunity to review the data, explain the results, and set up an appropriate diagnostic path if necessary.

With a progress note, the information being shared, which can be sensitive, is useful for providers who assume care along the continuum. Progress notes have their own style, which providers are trained to interpret. Patients generally are not trained in reading or interpreting a progress note. Therefore, any attempt could lead to confusion and unnecessary anxiety. For this reason, it’s often best if the information shared with a patient is curated. In general, progress notes should be left in the hands of health care professionals and not placed in the patient portal.

Clinical Documentation
Clinical documentation specialists (CDSs) gather clinical information from the chart and submit that evidence to providers to determine whether a more specific diagnosis is present. It is not hard to imagine that a patient seeing this evidence and any queries to the provider could jump to a conclusion before a physician (or other provider) has had an opportunity to review the evidence and make a clinical judgment.

For example, take obesity. In the CDS world, obesity—or, more accurately, specification of the level of obesity—is a common query. However, many patients are sensitive to documentation concerning weight issues. To avoid patients becoming upset, it’s best this information be excluded from viewing until a provider has had the opportunity to confirm that it is indeed an appropriate diagnosis.

CDSs also query often about mental health diagnoses, as well as other conditions that a patient might not be aware of that require a medical professional’s interpretation.

What to Include
A more appropriate use of a patient portal is to feature patient education material, which can accompany just about any diagnosis that has been confirmed by a provider. This information is reviewed and confirmed by professional organizations to ensure it accurately illustrates diagnoses and appropriate treatment plans in a more layperson-friendly manner—much more so than any progress note could.

Sharing every note in the medical record could expose providers to all types of scrutiny that would be counterproductive to following a proper diagnostic path. In general, patient portals should be used as a tool to share curated information about diagnostic conclusions as well as appropriate treatment in the form of patient education. Patients have the right to all the information in their chart, provided they go through a well regulated process involving HIM professionals who will ensure that they receive their documents in a HIPAA-compliant manner. It is also essential that patients be provided an opportunity to discuss their medical record documentation with a qualified professional.

— Reggie Ahlfield, MBA-HA, BSHI, RN-BC, is a clinical documentation improvement specialist at the University of California Davis Health System in Sacramento, California.