Study: Patients’ Social, Emotional Health Not Documented by PCPs

Study: Patients’ Social, Emotional Health Not Documented by PCPs

A study of medical transcripts in primary care revealed that physicians discuss but don’t document patients’ social, emotional health in the EHR.

Medical Transcription Services United States

Primary care practices are the patient’s first entry point into the healthcare system and serve as the ongoing focal platform for all needed health care services. Understandably, primary care providers (PCPs) are on the front lines of discussing not only the patients’ medical problems but also their social and emotional health, including psychosocial topics such as the patient's work life, finances and emotions. Family practice medical transcription services help PCPs ensure that all aspects of the office encounter are properly entered in the electronic health record (EHR).

However, the American Academy of Family Physicians (AAFP) recently reported on a new study which found that family physicians tend to prioritize what they enter in the patient’s EHR and often neglect documentation of social and emotional health concerns. This can have far reaching impacts on the patient’s care, say the researchers.

The

integrity

of

the

EHR

depends

on

comprehensive,

accurate

documentation. The patient office visit note or outpatient clinical note contains all the information that the physician has gathered before and after the exam. Specifically, this includes: 

Purpose of the visit: why the patient has come to the clinic, which could be for general care; or routine/scheduled follow-up; or addon/urgent visit to address a specific concern/issue



Chief complaint



History of present illness



Problem list



Past medical history



Medications



Adverse drug reactions and allergies



Social and family history



Review of systems



Physical findings

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

Assessment



Plan of care



Follow-up information

The EHR is aimed at improving the quality of clinical notes with provisions to document all the key components of the office visit. However, researchers at Ohio State University in Columbus and OSU's Wexner Medical Center in Grandview found that clinicians focused only on documenting medical complaints in the EHR. While they were aware of the intimate details of patient’s life and circumstances, and discussed their social and emotional concerns,

time-constrained

family

practitioners

did

not

record

these

concerns in the EHR. While a distinction is made between the mind and body, mental health and physical health are interrelated. Poor mental health has been shown to be harmful to physical health. For instance, studies have shown that people with the highest levels of self-rated distress (compared to lowest rates of distress) were 32% more likely to have died from cancer, and that depression is linked to an increased risk of coronary heart disease (www.mentalhealth.org.uk).

The study was based on an analysis of 10 physician/patient encounters that took place in 2016 in a Midwestern medical center using same EHR system.

Nine of the clinicians were specialists in internal medicine and one was a nurse practitioner. The researchers examined the internal medicine medical transcripts and

recordings

of

these

patient-clinician

encounters.

The

discussion topics were categorized as:



Chronic conditions or long-term pre-existing condition that was considered an ongoing problem, e.g., diabetes or hypertension; www.medicaltranscriptionservicecompany.com

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

Acute/new problems such as either a recent problem of which the clinician was previously unaware or a complaint that had been treated and addressed;



Disease-prevention discussions: screening tests and vaccinations



Social and emotional health, including psychosocial topics such as a patient's work life, finances and emotions

Their findings on documentation of the topics and average discussion time in these four areas are as follows: 

Chronic conditions were documented 90.4% of the time, with length of conversation was 9 minutes, seven seconds



Preventive care was documented 88.9% of the time, with discussion time five minutes, 59 seconds



Acute and/or new problems documented 84.2% of the time, with discussion time three minutes, 33 seconds



Social and emotional health, documented just 30.6% of the time, with length of conversation, five minutes, 49 seconds.

“We found that physicians were more likely to focus on the documentation of clinical complaints and less on social and emotional factors -- which have been shown to drive a patient's health care decision-making," noted the authors. Not recording pertinent social and emotional information in a patient's medical record would affect patient care in many ways: 

Clinicians involved in the patient’s care that do not have this information may prescribe an intervention that is not feasible for the patient.



Medical decisions and recommendations made without information on patients’ emotional and social concerns can make it difficult for the patient to comply with care plans.

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A 2011 article in Healio Orthopedics Today reported on the patients’ emotional status and outcomes in orthopedic areas such as spine, trauma, sports medicine, joint reconstruction and upper extremity surgery. The article cites orthopedic surgeon David C. Ayers as saying, “Patients with lower emotional health have a greater risk of less functional improvement after surgery.” Ayers points out that once a patient is identified as high risk, the orthopedic surgeon may be able to improve a patient’s postoperative function by enrolling the patient in a postoperative recovery pathway that provides the additional resources to address their anxiety, and provide them with coping skills and support.

The authors of the AAFP published study noted that time-constraints could be the reason for incomplete EHR documentation. Physicians find EHR documentation much more burdensome and time-consuming than handwritten notes. With tight appointment schedules and many patients with complex, multimorbid disease, physicians have little time for comprehensive documentation.

Physicians can consider partnering with an experienced medical transcription company that provides family practice medical transcription services to ensure complete and accurate clinical documentation and improve patient care.

www.medicaltranscriptionservicecompany.com

918-221-7809