Using EMR Addendums for Back-and-Forth Conversations About Patients: Documentation Concerns
Direct Answer
Yes, using addendums to have back-and-forth conversations about patients in the EMR is problematic and should be avoided. This practice contradicts fundamental principles of clinical documentation, which should prioritize clear, concise communication that supports patient care rather than serving as an internal messaging system 1.
Why This Practice Is Problematic
Violates Core Documentation Principles
The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication, not to serve as a conversation thread between providers 1.
The American College of Physicians emphasizes that documentation should consist of concise, history-rich notes that reflect information gathered to develop an impression, diagnostic plan, and recommended follow-up—not fragmented conversations 1.
Using addendums as a messaging system creates exactly the type of "note bloat" that guidelines warn against, where key findings and actions become obscured by superfluous documentation 1.
Creates Information Chaos and Safety Risks
Back-and-forth addendums systematically incentivize information duplication and information scattering, making it difficult for subsequent providers to quickly find critical information 2.
This practice forces clinicians to search through multiple addendums to piece together the current care plan, which increases the time spent on medical records and contributes to medical errors 2.
Research demonstrates that fragmented communication in the EMR is associated with decreased face-to-face communication and worsened overall agreement about the plan of care 3.
Patient Access and Transparency Issues
With the open notes initiative, patients now have immediate access to their medical records 1.
Conversational addendums may contain informal language or incomplete thoughts that were never intended for patient viewing, potentially causing confusion or concern 1.
Documentation should be written with the understanding that patients will read it, requiring clarity and completeness rather than fragmented exchanges 1.
Legal and Compliance Concerns
Courts consider clinical documentation to be discoverable, and the existence of an unaltered contemporaneous medical record is considered a more trusted source of truth 1.
Multiple addendums containing back-and-forth discussions can appear as if the record is being altered or manipulated, rather than serving as a clear contemporaneous account 1.
What to Do Instead
Use Appropriate Communication Channels
For real-time clinical discussions, use secure messaging systems within the EMR that are separate from the permanent medical record 4.
The American College of Physicians recommends that electronic communication between healthcare providers should occur within established professional relationships with appropriate documentation, but this should be in designated communication tools, not addendums 4.
For urgent matters requiring immediate input, use phone calls or face-to-face communication, then document the outcome once in the medical record 5.
Proper Documentation Approach
Each provider should create a single, complete note that synthesizes the current clinical situation, assessment, and plan 1.
If additional information becomes available after a note is completed, create a new dated entry or addendum that stands alone as a complete update, not as a response to another provider's comment 1.
Documentation should be organized by clinical topic or problem, making it easy for any provider to quickly understand the current status 2.
Collaborative Documentation Best Practices
Modern EMR systems should facilitate real-time, fully collaborative documentation where multiple clinicians can contribute to a shared understanding of the patient's care 2.
Use structured communication tools like information checklists to ensure all essential information is accurately provided between healthcare professionals 4.
Maintain appropriate boundaries and recognize that electronic communication merely supplements face-to-face encounters 1.
Common Pitfalls to Avoid
Never use the medical record as a substitute for direct communication when real-time discussion is needed 5, 3.
Avoid creating multiple short addendums that require readers to piece together information—this increases cognitive load and error risk 2.
Don't assume other providers will read through multiple addendums to find critical information; key findings should be clearly documented in the primary note 1.
Remember that all documentation may be viewed by patients, so avoid informal language or incomplete thoughts that could cause confusion 1.