Exploring the Patient's Lifeworld: A Qualitative Study of Personalizing Language in Electronic Health Records

Area of Science:

• Medical Informatics
• Qualitative Research
• Patient-Centered Care

Background:

• Physician documentation of patient personal details in electronic health records (EHR) can enhance relationships and patient experience.
• The extent and nature of personalizing language in physician notes are not well understood.

Purpose of the Study:

• To determine the prevalence and types of personalizing language used by physicians in clinical encounter notes.
• To analyze the content of personal details documented in history and physical (H&P) notes.

Main Methods:

• A cross-sectional qualitative content analysis was performed on physician-written H&P notes.
• Inductive content analysis identified personalizing language related to patients' identities, social context, and life experiences.
• The study analyzed notes from adult patients on an internal medicine inpatient service at an urban academic hospital.

Main Results:

• 60% of H&P notes contained personalizing language, with a median of 2 instances per note.
• The most frequent domains documented were family (41%) and work/education (32%).
• Detailed patient perspectives, feelings, or goals were rarely documented (1.9%), and personalizing language was more common in notes for male patients.

Conclusions:

• While most physician notes include some personalizing language, the depth of detail regarding patients' inner lives is limited.
• Further research is needed to explore patient perceptions and the impact of personalizing language on physician-patient relationships.
• Enhancing documentation of patient goals and priorities could improve holistic care.