Comparison of Documentation Models Used by Emergency Physicians in a Community Hospital Setting

Abstract

Physician notes are a unique genre within a larger genre ecology of a hospital's emergency care department. As such, they mediate activities of medical care and may also be appropriated for other uses such as billing and representing the patient's identity for patient-centered care. These additional uses may exert pressure upon the genre/genre ecology and contribute to its evolution. This study examines four documentation models used at different times over a twenty-year period at a community hospital and describes some of the changes to the genre of the physician's note along with the concurrent changes to the tools used to produce it. The study results demonstrate how the use of the genre for billing purposes has resulted in an increase in the number documented elements that pertain to billing and coding practices; it further demonstrates that there is considerable variability among the models in terms of how physician documentation reflects the elements of patient-centered care, which include patient needs, preferences, and values; coordination and integration of care; information, education, and communication needs; physical comfort; emotional support; and involving family and friends in care. The study findings suggest that there is an opportunity to improve patient-centeredness as represented within the genre of the physician's note. Tools within the genre ecology to which the physician's note belongs have the power to facilitate the conversations that both physicians and patients believe are important, thereby increasing the degree of patient-centeredness within the activity system of patient care. Technical and professional communicators are uniquely equipped to contribute their knowledge of genre and genre ecologies when electronic medical record system design and configuration decisions are being made in order to help assure that the genres used in health care lead to actions that benefit patients and practitioners.