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The computer era changes the ground rules for what constitutes useful content in a note. The goal is to get information committed to computer storage in a way that will be useful to both the computer and the practitioner.
Did you know that September 19 is "Talk like a Pirate Day," the day on which you are supposed to lace your speech with pirate-like expletives? While colorful, these flourishes add little of value. Similarly, narrative notes, especially if dictated, are often laced with flourishes that add little information content and sometimes obscure the meaning.
Fortunately, human listeners and readers have an immense capacity to reprocess what they read in the medical record. They can often ignore the chaff, infer the intended meaning of poorly worded notes and fill in the blanks with the aid of their training and experience. The computer era changes the ground rules for what constitutes useful content in a note. The goal is to get information committed to computer storage in a way that will be useful to both the computer and the practitioner.
Most of the value that we expect a computer to add depends on its ability to find and use what we enter as data. If narrative notes continue to be written the way they are today, they will prove to be very poor sources of data, even if they are excellent sources of information to a human reader. Since computer systems lack the ability to interpret and draw inferences, they need an assist from us.
The easiest way to provide an assist to a computer is to "talk like data." What does that mean?
1. Consistency - The most important single thing that can enhance the data value of an entry is to always use the same word to mean the same thing, spell it the same way (including any use of capitalization) and never use an abbreviation that you invented.
2. Terseness - Lead off with the fact or item that you are attempting to describe, then follow with any qualitative and quantitative modifiers that are needed to fully explain the entry. Examples: Systolic Blood Pressure, 145, mm Hg, left arm, by cuff. Tympanic Membrane, right, red, bulging.
3. Ability to parse - To parse is "to analyze (a string of characters) in order to associate groups of characters with the syntactic units of the underlying grammar." Each modifier should be delimited from the others by some punctuation such as a comma. The punctuation that is chosen should be used consistently. If commas appear in the meaningful content, then choose some other mark such as a semi-colon.
4. One thought per sentence -When recording information, limit each sentence to asserting a single informational element such as a finding, result or conclusion.
The more the information you record in your EHR is data-like, the more valuable it will be as data. This concept can be applied to any EHR. If these guidelines are followed, it will be easier to extract and use data from narrative notes.
The good news is, you don't have to wait until September 19 and you don’t have to talk like a pirate, but you can and should talk like data every day.
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