As noted previously, I love electronic health records. I love them despite their many (many) problems because I truly believe that most of these problems are fixable. In order to be fixed, however, one must clearly and persuasively identify what the problems are. So that the healing – er, fixing – can begin.
What follows is an example of one of my top issues with EHRs. This is the entire HPI for a note I recently stumbled upon, verbatim (minus any identifying info, obvs):
“sexual health history:
19 year old female presents with c/o Female reproductive OR GYN category Engages in sexual intercourse with Both, Last sexual encounter about 1.5 mos ago, Number of different sexual encounters/partners in the past six months 1, Currently sexually active with Not currently active, History of vaginal intercourse: If yes, are condoms used? Always, History of STIs testing: Yes, History of STIs: No, Pregnancy prevention practices: Yes male condoms.
c/o menstrual cycle normal, LMP 1/9. c/o frequent urination for few days daytime and night time, urgency. c/o vaginal symptoms for few days itching, foul smelling discharge. c/o burning w urination.
Denies : abdominal pain. fever. hematuria.
c/o R lwr back pain.
Denies : abnormal vag bleeding. “
What are the chances that someone actually wrote this? Meaning, someone’s brain decided to assemble these words into these patterns, pretending to have produced coherent sentences? Roughly zero, right?
Thank you, templates. You are responsible for this complete abomination of medical documentation.
Seriously. “Presents with c/o Female reproductive OR GYN category”? “Currently sexually active with Not currently active”?
WHAT DOES THAT EVEN MEAN? WHAT DOES ANY OF IT MEAN?
I mean, it sounds like she’s here with a few days of dysuria, urinary frequency, vaginal discharge and itching. I get that. But it takes far longer than it should for me to get there. And that sexual history is a mess. And – most importantly to me – THESE ARE NOT REAL SENTENCES. They shouldn’t pretend to be.
If you want to use templates for your review of systems, fine. If you want to use them for your physical exam, fine. If you want to use them to review patient education materials provided, fine. I won’t love any of it, but I’ll tolerate it.
But I just cannot get on board with using templates for the HPI. The History of the Present Illness is what the patient tells you about how they ended up sitting in front of you today. It’s a story, a narrative. To give that story justice, it should be documented accordingly. Huge swaths of meaningful information are completely lost when your patient’s narrative is reduced to a bunch of little buttons clicked clicked clicked – “present” “absent” “denies” “yes” “no”… NO. Hate doing it, hate reading it.
Am I missing something? Does anyone have a defense of the template-based HPI?
But seriously, if you’re in love with HPI templates and consider them to be demonstrably superior to free-texting (a.k.a. WRITING) the HPI as a narrative, please, clue me in on how you’re making this work for you.
As long as your HPIs don’t look like this one. Because if you consider that mess to be superior to anything beyond tossing a bunch of Scrabble tiles in a pile and then randomly lining them up, then I’m not sure I can trust anything you have to say.