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Patient Access to EMR – Do Physicians Need to Use Simple Language?

Patient Access to EMRThe federal government recently issued guidelines to make it easier for patients to access their medical records – unconditionally. The goal is to make it easier for patients to actively participate in their health care, which can improve outcomes.  Open access to electronic medical records (EMRs) has put the focus on the physician’s narrative style, something that a medical transcription service provider can decipher, but which may prove difficult for the layman.

A study that looked into the impact of patient-accessible electronic medical records in rheumatology showed that many patients felt more involved in their treatment with the web portal model that offered home EMR access. It therefore improved the care process. Many rheumatology practices rely on professional rheumatology transcription services for reports integrated with EHR software, enjoying benefits such as improved patient care, billing processes, and improved communication with referring physicians.

A recent article in the Star Tribune notes that with unrestricted access to EMR, physicians are faced with a new dilemma – do they need to use simple language that patients can follow or continue to use typical jargon and acronyms that are familiar to other health care providers?

Terms that Physicians Use

Experienced medical transcriptionists are familiar with the abbreviations and medical slang that physicians routinely use in their narratives, though these could prove confusing for patients. Here are some examples:

Medical Acronyms:

BSOFP – blood spotted on filter paper
EMU – early morning urine, energy-mode ultrasound
PRN – as needed
RCIRF – radiologic contrast-induced renal failure
TeBG – testosterone-estradiol-binding globulin
NPO – nothing by mouth
VSS – vital signs stable

A few examples of the abbreviations that rheumatologists use:

IC – immune complex IC
DISH – diffuse idiopathic skeletal hyperostosis
TBBMD – total body bone mineral density
CTD – connective tissue disease CTD

Common Medical Jargon:

Bagging – Artificial ventilation performed using a respirator bag
Code brown – Incontinence related emergency
Crasher – Someone who passes out in ER (usually family member)
Frequent flyer – Patient who repeatedly shows up in ER

Commenting on the new guidelines instructing providers to provide patients with access to personal health information, advocates for the movement say that physicians may need to rephrase wording in patient records.

The Other Side of the Picture – Maintaining Compliance

Experts point out that changing the culture of note taking and using definitive medical language could cause diagnostic and billing problems. For instance, a patient could object to the use of the word “depression”, but it is necessary to use this tem to ensure accurate coding and claim submission. In fact, medical transcription services have an important role in improving physicians’ documentation practices for proper reimbursement.

HIPAA-compliant transcribed reports can be integrated with EHR software to improve patient care, billing processes, insurance claims, practice-wide communications and feedback to referring physicians.

Informed Patients Can Take Better Control of their Health

The scales are tipped in favor of allowing unrestricted EMR access. Many patients use the Internet to educate themselves about the information in their doctors’ notes. Malpractices insurers support the practice too as they believe that informed patients reduce litigation risks. Accurately transcribed patient records are also valuable because they remind patients about their physicians’ instructions.

About MTS Team

MTS Team

Medical transcription service company offering quality medical transcription outsourcing services to hospitals, outpatient clinics, physicians and health care facilities of all specialties and sizes across US and Canada.

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