Providers’ Note-Writing Practices for Post-traumatic Stress Disorder at Five United States Veterans Affairs Facilities

Abstract

The capacity of electronic health records (EHRs) to capture desired information depends on the practices of health care providers. These practices have not been well studied in relation to post-traumatic stress disorder (PTSD). This qualitative study investigated how providers write EHR notes on PTSD through 38 interviews with providers working at five Veterans Affairs (VA) hospitals across the United States of America. Two overarching themes were prominent in the results. Providers used progress notes primarily to remember and access details for direct patient care, but only rarely for care coordination. Providers infrequently recorded information not judged to directly contribute to improved care, sometimes deliberately omitting information perceived to jeopardize patients’ access to, or quality of, care. Omitted information frequently included sexual or non-military trauma. Understanding providers’ thought processes can help clinicians be aware of the limitations of EHR notes as a tool for learning the histories of new patients. Similarly, researchers relying on EHR data for PTSD research should be aware of likely areas of missing data.

Appendix 1

Guide to Provider Interviews

Open-ended cognitive prompt

First can you tell me in your own words your thoughts on how you constructed the record? Just walk me through what you did first, second, third (etc.) and why you did it this way.

Data location

• 1) So when you started writing the note, what was the note title that you used?

• 2) To set some context, please tell me briefly how long you’ve been seeing this patient, and approximately how frequently.

• 3) Why was the patient in clinic on this occasion?

• 4) Did you have to choose which note title to use? If yes: was choosing the note title easy or difficult, in this case? Why?

• 5) Did you create entries under any other note titles associated with this visit? What were they?

Template use

• 6) Did you use a template to create this note? If yes - Is it a template you created, or did someone else create it?

Identifying continuity and change

• 7) Were there some parts of this note that you created before your visit with the patient? If yes and probe is necessary: can you point out those sections, please.

• 8) What information do you always record for a patient, every visit?

• 9) Did you look back to previous notes on this patient to borrow any language that you used here?

• 10) Did you look at other notes for other reasons?

• 11) How far back did you look?

• 12) Could you always find what you were looking for? If not, what made finding the information difficult?

• 13) What information recorded here indicates a change since you last saw the patient?

Ability of notes to capture important information

• 14) What clinical information was most important to you to record in this note?

• 15) Is there anything interesting about this visit that you remember that you didn’t include in the note?

• 16) Was there anything that was important but that you felt there was a good reason not to include? If yes, and prompt is necessary: why was that information not recorded? Was there not a place to record it or is there a reason you decided not record that information?

• 17) Is there anything you wrote in the note that you intended to really stand out and be noticeable, either to yourself or to others reading the note? If yes, and prompt is necessary: how did that desire to make this information noticeable influence the wording you used?

• 18) Other than documenting that the visit occurred, does this note serve a particular purpose for you? If yes and prompt is necessary: what was that purpose, and how did that influence what you wrote?

Use of vague language/omissions

• 19) Is there anything in this note that you wrote in such a way that it is intended to remind you of some detail, without actually putting it in writing?

• 20) Was your wording in this note affected in any way by the people you expect to read the note - for example, other providers, or Department of Defense personnel, or the patient? If yes and probe is necessary: can you describe how this influenced your word choices?

Key word use/location

• 21) What are the key terms, if any, that you would always be sure to include in your notes in describing a patient like this one?

• 22) Did you consider using the term “resiliency” in writing this note? Are there other terms you use that you feel mean the same thing?

• 23) Did you consider using the term “recovery” in writing this note? Are there other terms you use that you feel mean the same thing?

• 24) Can you describe how you decided on the language you used here to talk about suicide risk or suicidality?

• 25) Can you describe how you decided on the language you used here to talk about any substance use?

• 26) Do you find it useful to record information about the patient’s living conditions or social interactions? If yes: where do you record that kind of information?

• 27) Do you record information about patient-reported interactions with the legal or criminal justice system?

Recording of quotes/patient vs. provider words

• 28) If you include information in the note at a patient’s request, do you indicate that request in some way?

• 29) If a patient makes a statement that you feel should be recorded, but it is in conflict with your assessment – for example, the patient says “I’m really feeling so much better,” but appears to have poorer functioning – do you usually indicate that conflict?

Provider Communication

Did you write anything in this note with the direct purpose of communicating with another specific provider?

Time use

Finally, about how long did you spend writing this note the first time, do you think? What took the most time?