The days of handwriting case notes may shortly be a thing of the past. With the new technologies available today, clinicians are being liberated from their handwritten notes. Some of the new technologies that have evolved over the past few years include:
1. Text processing systems
2. Integrated word processing
3. Voice recognition
4. Voice mail dictation systems
5. Electronic document imaging
Text Processing Systems:
The first generation of automated treatment plan systems was created within the traditional data processing system. The software developers simply added large alphanumeric fields to a data entry screen and allowed the user to record their notes. The early versions of this type of software were very limited in their ability to process text. As users became more sophisticated and demanded more editing capability, the vendors created their own text editors. These systems provided the clinician with the ability to perform some simple editing functions. They could cursor around in the text, insert, copy, delete and perform operations on blocks of text. Although limited in function, these systems have the advantage of linking a note or assessment to a clinician, patient, service and date.
Integrated Word Processing Systems:
As more and more clinicians have experience with word processors the demand has increased for the vendors to develop interfaces with the popular word processors like MS Word for Windows and Word Perfect. With these second-generation systems the user can jump directly into the word processing program from the clinical record software and back again. All of the functionality of the word processing software is then available to the user. In the older interfaces, the file created by the word processor was not well integrated with the mental health software.
Therefore, the user did not have the advantage of being able to locate a note through the data processing system. As a consequence, an individual note was difficult to find. Often, all of the notes for a particular patient had to be scanned sequentially and read individually to locate the one of interest. Obviously, this was a very time consuming and inefficient method of automating notes.
The newer systems have much tighter integration and even provide the capability to merge data from the mental health MIS into the note created in the word processor. The user can create glossaries for coded entry of text and evoke mail merge features to automatically insert text from other areas of the client's record.
This saves the clinician from having to look up and type data that are already in the patient's database like name, address, presenting problem, diagnosis, medications, date of service, type of service, location of service, level of functioning, level of service, etc. Additionally, these systems also allow the user to create macros to perform formatting functions and to insert standard phrases, sentences and paragraphs. Another attractive feature is the ability to link notes to specific areas of a treatment plan, assessments, or just create a global note related to the client.
The systems also automatically link notes to a specific service. Most systems automatically secure the note so that once it is closed it cannot be modified. Notes are also date and time stamped and linked to other variables that can be searched for easy retrieval. The advantage to this approach is that the clinician who is familiar with word processing can prepare their notes directly in the system and use the editing, spell checking and macro capabilities of the software to reduce typing, errors and standardize the format and content of the note. The disadvantage is that you need a PC and must be able to type. Further, files created by word processing systems are less secure. They can be accessed by non-authorized staff and are easy to view and copy onto a floppy disk.
Voice Recognition:
The latest advance in the preparation of progress notes is the use of speech recognition technologies. These products have been around for several years, but only recently have been refined to the point where they can be used in a production environment. The systems are software based and work in conjunction with most 16 bit sound cards and microphones. The applications software comes with their own dictionary and allows the user to define their own custom dictionary of words, names and phrases. Special modules are also available for various professions like medicine, mental health, law and engineering.
The voice recognition programs can be used with most Windows-based word processors so it is not necessary to learn another system. In addition to speech recognition, most systems provide the clinician with the capacity to edit, copy, move, delete and format text as if you were using the keyboard and mouse.
Further, the user can access all pull down menus and dialog boxes to initiate commands. Although some speech training may be required for the system to learn your speech patterns, the systems will automatically adapt to your voice during use. The software allows for natural phrases and continuous speech.
Numbers can be read in as discrete numbers, one, three, seven or as a phrase, e.g. one hundred and thirty-seven. One disadvantage is that discrete letters must be read in as military codes, e.g. a = alpha, b = bravo, etc. The commands that require use of a mouse can be activated by voice commands that position the cursor on the appropriate menu. If desired, a clinician may record standard phrases or paragraphs and through voice recognition insert them automatically into a document. At least one software vendor has integrated voice recognition into its mental health information system.
Miscellaneous Products:
Other methods for recording progress notes have evolved over the years including: the use of network based voice mail to record and transcribe notes, scanning of handwritten and typed documents and scanning typed or handwritten documents through OCR and ICR.
Planning for Automation:
Many agencies acquire a huge number of forms. It is not uncommon for the authors to encounter 15 different "Progress Note" forms in a single organization. To prepare for automation, organizations can benefit from a structured process of reviewing all forms, not only Progress Notes, for consistency of data elements, format, routing, and coding. Forms should also be grouped by their function (e.g. assessment, planning, discharge, reporting, etc.).
When professionally conducted, pre-automation streamlining can be done to coincide with typical automation modules, greatly enhancing the transition to a "computer" system.
About The Authors:
Bruce Johnson, M.S., is President of Johnson Consulting Services, Inc., an information management consulting firm that specializes in working with healthcare, social service and managed care organizations. He can be reached at (800) 988-0934, www.jcsconsultants.com or by e-mail at jcs@eos.net. Mr. Schafer is a clinical records and operations management consultant. He specializes in working with managed care, behvavioral healthcare and child welfare organizations. He can be reached at (800) 661-2435, www.schaferconsulting.com or by e-mail at steve@schaferconsulting.com.
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