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Controlled Medical Vocabularies by Joel Diamond

06/03/2009

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More pearls form the CMO of dbMotion

Controlled Medical Vocabularies

http://www.histalkpractice.com/2009/06/02/joel-diamond-6209/

Joel Diamond 6/2/09

Controlled Medical Vocabularies

In my last post, I discussed how our current coding systems just don’t suit the needs of everyday working physicians. For some reason, it got me all nostalgic for the good old days of paper records. Nothing like curling up in front of the fireplace with an old novel. Ahh … the texture, the smell …

OK, the reality of paper charts: falling apart, disorganized, and an odor best characterized by the last body orifice examined.

My EMR records are so much more complete and accurate, yet I will admit that there are subtleties that are often lost. For instance, my long-since retired, older partner was fond of writing F.I on the front of certain patients’ charts. This was to boldly remind him that a patient was a “(expletive deleted) idiot”. I remember when I first went into practice, one of his patients was staring at the outside of her chart while I was talking. “Dr. Diamond”, she asked, “what does F.I. mean on my chart?” Thinking quickly, I blurted out that my aging partner liked to label only the charts of his favorite patients, designating them as “fine individuals”.

Then there are the long-lost abbreviations written in the margins of countless charts — meant to convey a certain nuance that is sadly missed in today’s templated notes. Most of us fondly remember the sign-off on complicated VA patients: AMF YOYO– an encouraging “adios, mother (expletive), you’re on your own”. The essence of a patient’s condition could often be wrapped in the gallows humor of a cryptic abbreviation: ART (assuming room temperature), FTD (fixing to die), or an order for PBAB (pine box at bedside).

The term SWAG written next to a differential diagnosis conveyed to the reader that this was just a “scientific, wild-ass guess”. The conclusion to a discharge summary, TTGA (told to go away) somehow told the real story. An opening description such as LOLINAD (little old lady in no acute distress) will be missed as much as the politically incorrect description of the pediatric patient’s parent, GLM (good-looking mom).

Don’t get me wrong, I strongly advocate the use of CMT (controlled medical vocabularies). Codifying information in reproducible terminology is necessary for a true longitudinal record, which can be used for analytics and research and effectively allows communication amongst the health care team.

It’s just that some days, I miss chuckling as I enter the exam room — wondering how I’d explain my old partner’s unabashed label of his opinionated and misinformed patient as ABITHAD (another blithering idiot, thinks he’s a doctor).

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh, and a practicing physician at UPMC and of the Handelsman Family Practice in Pittsburgh, PA. He also blogs on interoperability.

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