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Monday, November 27, 2017

Documentation Design: Palliative Care Notes in the EHR Era

by April Krutka (@April918) and Christian Sinclair (@ctsinclair)

DOCUMENTATION...who knew this one word could provoke so many emotions among health care clinicians? Say this word, and you will hear stories of triumph and defeat. From universal required elements in the admission history and physical, progress notes and discharge summaries to the specialty specific language of advance care planning and pain assessments, there is a constant pressure to get all the pieces to fit correctly. Moving from analog to digital offered much hope, but also new problems. Before we even start typing or dictating a new note, most of the success or failure lies in how we design our notes from the start.

Standardized documentation promises clinicians consistency, data tracking, opportunities for quality improvement, and inclusion of essential elements of a specialty. If a template is built well, it should save time and impact the clinician experience and patient care in a meaningful way. Designing templates can be like walking a tight rope. Fall on either side, and it can lead to burnout and frustration by those using the templates.

There are many stakeholders who have a vested interest in the components of a clinical note. It is used by many different entities for different reasons: the billing department wants to submit the correct bill, the clinician/team needs to communicate clinical plans, the patient wants to be assessed accurately and without stigma, payors want to make sure they are paying for value, risk management stresses timeliness and compliance, health care administration wants to make sure all of the above are being done well. We are asking a lot of our notes and the templates that guide them. And for tools like these that are used millions of times daily, there is not much research or quality assessment involved in these vital communication platforms.

Palliative care documentation and templates also present unique challenges, as palliative care is provided in an interdisciplinary setting, tells personal story outside of standard medical issues and must relay the overriding goals that drive the creation of a medical plan. If we are successful, we are able to tell a human story, effortlessly meet billing standards, communicate seamlessly with all parties involved, save time, and track the spectrum of suffering or comfort and quality metrics.

This is the first of many posts over the next few months as we prepare for our presentation "Documentation Design: Palliative Care Notes in the EHR Era" in Boston at the Annual Assembly of Hospice and Palliative Care in March 2018. (Psst it is Friday, Mar 16th at 3pm, make sure you come!) We are very interested in hearing about your challenges and successes!

We are kicking it off with a #hpm chat, Wednesday Nov 29, 2017 at 9p ET/6p PT. We will post here and on the AAHPM Connect Forum to seek your input to help make our talk meet your needs. (Sign up on to get alerts to upcoming chats!) Topics we will be covering in the chat include: Templates: love them, hate them, what works best for you? Should we consider different types of notes for different reasons or make them all try in fit in our usual current note types? How can we make the EHR work for us and not the other way around?

April Krutka is a palliative care physician at Intermountain Healthcare in Utah working on the Cerner EHR. Christian Sinclair is a palliative care physician at the University of Kansas Health System working on the EPIC platform.

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