Standardizing Clinical Documentation is No “LOL” Matter

In 2011, FYI, LOL, and OMG were added to the Oxford English Dictionary solidifying the language of SMS (short message service) into our vocabulary.

Texting shorthand, or abbreviating, is becoming a mainstream universal language for expressing emotions, thoughts, and important information.

While texting may be suited for other day to day communications, is it suitable for EHR documentation? A new generation has entered the healthcare workforce and they are bringing text language into clinical documentation, according to Erin Glanz, Director of Perioperative Product Management and Shared Services at MEDHOST.

Clinicians separated by generational gaps—those who have historically handwritten all of their clinical documentation and those who are more accustomed to abbreviating—are sometimes experiencing breakdowns in communication. As a result, clinical documentation inaccuracies can place patient safety at risk. In addition, as misdirection and miscommunication rise, it can also interrupt the flow of care in a complex industry.

Unsystematic Clinical Document is a Patient Safety Issue

The transition from paper to electronic documentation has still left some hospital staff scratching their heads. Learning to do things a new way is hard, but a hospital can plan for basic EHR training by establishing a policy for abbreviations in clinical documentation.

For example, a new generation of healthcare professionals may wrongly assume that the abbreviations they use every day are understood by all their peers. IMO (in my opinion) can easily turn into IMA (inferior mesenteric artery), at a quick glance. Errors like this can lead to misdiagnosis, which is a serious patient safety red flag. At the very least, going back to correct documentation errors related to abbreviations can draw out care and delay payment.

Using abbreviations and acronyms in patient records across “a heterogeneous community of healthcare workers” was linked to patient safety issues in a study published by Journal of Healthcare Communications. The study concludes that there is a need to standardize shorthand in healthcare across all settings.

“At one point with paper records we had too much to deal with, information overload,” says Glanz. “Now with digital records we easily provide too little information. Abbreviations are sometimes too short, too simplified, or just wrong.”

Glanz says that it will mostly fall on the facilities to train clinicians on proper abbreviations and shorthand usage. She also notes that there are a few tools MEDHOST has in place that can help hospitals make sure unapproved abbreviations do not hamper care.

How to Standardize Clinical Documentation Abbreviations

More than 60 percent of medication errors were linked to poor handwriting according to a study from the Center for the Advancement of Health (https://journals.lww.com/nursing/Fulltext/2016/07000/www.sciencedaily.com/releases/2007/06/070627084702.htm). A shift to digital documentation can help reduce errors related to illegible handwriting, but EHRs themselves are not a comprehensive solution. Errors in documentation can still occur via a keyboard.

How to Avoid Clinical Documentation Abbreviation Errors and Improve Patient Safety

1. Create a Documentation Policy

Establish a well-defined documentation policy. Before shorthand can run rampant on patient records the American Healthcare Informatics Management Association suggests hospital leaders outline:

  • How abbreviations are to be used
  • What abbreviations are allowed
  • Which abbreviations are prohibited

To help promote consistent clinical documentation, MEDHOST uses a templated system that can act as a guide for physicians. These templates help users save time and make sure information is being compiled with accuracy.

2. Perform Documentation Audits

Once rules are set in place for abbreviations and other documentation related tasks, hospitals should perform audits of patient records to check for common errors. Hospitals often work with MEDHOST on documentation audits and reviews. Regular documentation reviews can reveal recurring problems and point hospitals towards permanent solutions.

Reviews or audits also need to occur on frequent intervals. Fine-tuning of clinical documentation takes time, but when done on a consistent basis it can help reduce risk and improve care.

3. Focus on Documentation During On-Boarding

New employees, especially those who may be members of a text-prone generation, need upfront education on proper documentation practices to help catch errors before it’s too late.

The Lippincott Nursing Education Blog provides a list of documentation topics that should be covered during nurse on-boarding. These same tips can also be applied facility-wide and include:

  • What is important to document
  • Approved/prohibited abbreviations
  • Providing hands-on experience with clinical documentation tools
  • Documentation timelines
  • Specific skill areas for documentation

Senior clinicians or those who are well-versed in a facility’s documentation policies can also offer guidance to new staff members.

Changes in the way we communicate as a culture have made shorthand and abbreviations part of our modern vocabulary. Terms like BRB (be right back) are no longer just typed, but also spoken. In the same way hospitals adjust workflows for new EHR technologies, providers need to proactively promote digital documentation accuracy in an era of short message services.

Find out how MEDHOST can help your hospital document clinical data with more accuracy and consistency. Call us at 1.800.383.6278.

Further Reading:

How 5 Physician Documentation Methods Compare to Facilitate Safer Care

Help Maximize Revenue with Clinical Documentation Improvement

How Effective Clinical Documentation Can Protect Reimbursement

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