I promised in my last blog to provide examples of capturing EMR information in artful and disciplined combinations of narratives and of clickable lists and scales. For me artful and disciplined means the essential information, not more and not less, is presented in formats that best capture its significance and that best serve the therapeutic effort. But first a disclaimer: I have thought long and hard, alone and with others about these issues. I aspire to this “artful and disciplined” standard, but I have probably misled you about having achieved it. Anyway, here goes…
(NOTE: You can view screen shots of these examples in this document. The document also includes more discussion of the thinking and decision points leading to the final design.)
The patient has sought help because of a complex mix of events, feelings and behaviors. There is a story that must be told, heard and conveyed into your EMR. Only a narrative can convey the chronologies, emotions, conflicts and relationships involved. Traditional wisdom calls for the Chief Complaint/Presenting Problem to be captured in the person’s own words and the surrounding story (History of Present Illness) to be presented in narrative form. Depending on the treatment context, the narrative story-line can be continued through the past treatment, developmental and personal histories.
Of course, there are numerous elements embedded in the client's story. Many are interesting and relevant; but discipline requires that only those few that are important because of their risk, their impact, or their prognostic value be captured in structured formats. (In some settings, items are also included in reportable formats because of their potential relevance to research and outcome activities. Also most settings must collect certain information for administrative purposes.) For example, suicidal thoughts and behavior clearly meet this threshold. Dictionary based data fields can highlight the presence of suicidal risk, then help identify contributing and mitigating factors and finally communicate the assessed extent of risk. The attached document shows details. Other areas warranting abstraction from the story might include psychiatric hospitalizations, substance abuse, arrests, medical problems, family history of mental illness and so forth.
After having captured and selectively abstracted the story of the client’s problems, the clinician must synthesize the material into a clinical formulation. This integrative process needs narrative to fully portray its content. Then typically, the clinician must specify areas on which to focus the therapeutic work and identify facilitating and obstructing factors. These last are readily and usefully done with lists. Again the attached document shows details of such an effort.
As you can see, this is not rocket science. My point is that narratives and lists and scales are complementary.
