Silence in the EHR: infrequent documentation of aphonia in the electronic health record

Abstract

Background: To begin to deliver patient-centered care, providers need to be aware of when a patient has a communication disability and what communication methods to use with the patient. The aim of the study was to describe if and how patients' communication disabilities are documented within electronic health records (EHR).

Methods: A retrospective manual chart review of all inpatient and outpatient clinical encounter notes within the EHR for patients who had undergone a laryngectomy at Northwestern Memorial Hospital (Chicago, IL) between 2000-2013. We selected patients who had undergone a laryngectomy as the patient population as we were able to easily identify the patients through Common Procedural Terminology (CPT) codes.

Results: We identified 81 patient charts with 7484 encounter notes. Of the 81 patient charts, 58 (72%) had at least one encounter note with a communication notation. Excluding speech-language pathology notes, 1164 (16%) of all encounter notes included some notation of the patients' communication abilities. We coded the communication notations into four categories. 1) Descriptions of communication abilities appeared in 663 (9%) of all encounter notes, 2) descriptions of communication methods appeared in 590 (8%) of all encounter notes, and the last two categories 3) medical management and 4) referrals to speech-language pathology services each appeared in 148 (2%) of all encounter notes. While all patients had the same type of communication disability, aphonia, providers used 39 different terms and phrases to describe aphonia.

Conclusions: Patients' communication abilities were infrequently documented in the EHR. When providers did document a patient's communication disability or method, they used inconsistent descriptions, suggesting a lack of standardized language. Further work is needed to determine how to consistently and accurately document patients' communication abilities so staff and providers can quickly recognize how best to communicate with patients with communication disabilities.