Communication & Documentation - What is the Burden of Proof?

Electronic medical record (EMR) integration is certainly a hot topic for any technology in the healthcare world today. The push for integrating mobile communication solutions with the EMR seems logical, but perhaps there are some bigger questions to answer first.

While EMRs do a great job of providing digital documentation of a patient’s history of medical care, communication between those who care for the patient is often lacking. When documentation of a conversation is done as an afterthought, not as a means of communication, is it meaningful? While there are certainly times when shared data or decision-making processes need to be captured in the record, documenting that a conversation happened may be more useful than recording a complete transcript of the entire discussion.

Many who are pushing for communication threads to be included in the medical record may not understand the sensitive nature of conversations between caregivers. Not only may these communications be in medical shorthand or include social discussion mixed with patient care, they may include personal tidbits that a patient would not want to have as part of their record.

At DocbookMD, we believe it makes sense for a provider to choose what ends up in the chart, as they have always done in the past. After all, the medical chart is a document that belongs to a patient, where communication belongs to the ones talking. With solutions like DocbookMD, you have the best of both worlds: real time communication, with archived documentation of the thread. The provider chooses what belongs in the record and what does not.