In today’s electronic medical records, non-physician providers have to complete multiple assessment templates as a means of documenting the care and condition of patients. So basically patients are broken down into small snippets of information as determined by each template. Typically these templates are made of check off boxes or simple drop down boxes to facilitate completion. Some examples of individual templates include: physical assessment, vital signs, toileting, feeding intake, reposition, fall risk/precautions assessment to name just as few. And each template requires its own separate click to open and review.
One important lesson that is often overlooked: patients are typically more than the sum of their individual assessment templates. And when this is forgotten, it’s a problem
a Patient
Mr Y, 87 yrs old, has advanced dementia. He no longer recognizes his children and requires assistance for all activities of daily living. But Mr Y is still able to get out of bed and sit up in a chair for a few hours each day and he eats well and interacts with his family. His family takes meticulous and loving care of him, allowing him to remain in his own home.
Mr Y is now hospitalized for agitation, possibly secondary to a urinary tract infection. I was asked to meet with his family because this was his 5th hospitalization in 8 months.
I had a good discussion with his family, and although they understand the severity of his dementia, they feel he still maintains a good quality of life. But they are worried. With each hospitalization he become a bit more frail. They sometimes wonder if the burdens of hospitalization are becoming greater than the benefits.
I took this opportunity to affirm that their worries are well founded: in light of his repeat illnesses requiring hospitalization, it was quite likely that his overall prognosis was limited (using prognosis calculators he had a 50% chance of mortality within 6mo). So we discussed potential paths forward, including shifting to a more comfort focused approach to care. This was new information for them. They were quite relieved to learn that there was another path aside from the hospitalization path; and were very interested in home hospice support.
Before making the full transition however, they wanted to see if perhaps a short course of rehab in a local skilled nursing facility (snf) would get him back to his prior baseline. And whether he improved or not, after a week or so they planned to bring him back home with hospice support.
His care in the hospital shifted towards more comfort focused care as he completed the last 2 days of iv antibiotics and awaited acceptance at a local snf. But something changed over the weekend, because when I visited him on Monday morning, he was a different man. Mr Y was unable to get out of bed, was barely taking food or drink, and was sleeping most of the time. His decline had started earlier than anticipated and rehab was no longer an option. He either needed to discharge to snf or home with hospice support.
But he was still scheduled to be transferred to the snf for rehab later in the day!
It seemed that everyone involved in his discharge planning, from the hospital case manager to the snf liaison, had been checking on Mr Y by reading his electronic record- not by a direct visit. Somehow all seemed to think he was still a candidate for rehab.
How could this be?
One of the most valuable attributes of electronic medical records are that notes are now legible- so ‘I can’t read the doctor’s handwriting’ is no longer a viable excuse for misunderstanding. So I looked through his record to try to figure out what had happened, and when his change in condition had occurred.
What I found:
In the provider notes: The daily hospitalist note just said ‘unchanged’ in the area for subjective description. And there were no acute issues- such as a fever, or change in vital signs.
In the nursing notes: in 72 hours there were only 2 notes that were free text, all the rest (and there were plenty) were the completed assessment templates.
I reviewed each of these 54 separate assessments, an arduous task. But despite all of these assessments, I still had no idea what happened. For example, in the feeding intake- there was a mention of “only ½ of meal eaten”, but it didn’t say why or if it resolved or offered any attempt at explanation.
Trying to put all the assessments together to create a whole Mr Y was completely IMPOSSIBLE. There was just a blob of information describing electronic Mr Y, that really didn’t tell me anything.
But obviously, based on human Mr Y in front of me, there was a story that needed to be told, but it was camouflaged within the EMR
Each patient is more than the sum of their assessment sheets. I don’t think human brains are capable of putting all the information separated by screens and clicks together into a ‘whole’ and I am skeptical that artificial intelligence will be able to do this either.
My belief is that this takes a bit of prose…
more in the next post.
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