Though PET and DAT scans may aid the diagnosis of Parkinson’s disease or PD, it cannot differentiate PD and Parkinsonian subtypes. Clinical findings are still used to diagnose PD. However, a study published in the June issue of the Neurology Journal (the official Journal of the American Academy of Neurology) says the four main motor symptoms of PD including shaking or tremor, slowness of movement (bradykinesia), stiffness or rigidity of the arms, legs or trunk, and trouble with balance and possible falls (postural instability) are not unique to the disease but can be found in other neurodegenerative disorders. This implies the need to understand the patient’s health condition better and the importance of complete and accurate neurology documentation.
In order to diagnose PD accurately, the following information is essential according to the National Parkinson Foundation.
- A detailed medical history and details of physical examination
- A detailed history of current and past medications so that the neurologist can ensure the patient is not taking any medications that will cause symptoms similar to PD
- Results of detailed neurological examination
- United Parkinson’s Disease Rating Scale (UPDRS) recorded during the exam, which is a universal scale of PD symptoms and created to assess and document the exam of the patient comprehensively and compare it with the patient’s future follow-up visits or to communicate the progress of PD symptoms with other neurologists
- Response to medications
From this, it is quite evident that comprehensive and standardized clinical documentation is inevitable for correct diagnosis. Such kind of documentation can help neurologists to understand not only motor symptoms, but also non-motor symptoms of PD including cognitive impairment, sleep disturbances, depression and so on. The study author says if you follow the patients and study their responses to medications longer, the probability of making an accurate diagnosis is higher. This means timely clinical documentation comprised of medication response and details of follow up visits can facilitate correct diagnosis.
With built-in symptom based templates for gait disorders, sensory loss etc., and condition-based templates for PD, electronic medical records (EMRs) are quite effective at providing standardized clinical documentation. However, providers must ensure that they avoid errors such as missed data, incorrect data or incomplete data. Such errors will be propagated to other records quickly and the end result may be disastrous. Busy physicians can continue to make use of medical transcription services if they so prefer because reputable transcription companies offer value-added services in this regard. They allow providers to upload their audio files to the medical transcription company’s online platform, where their transcriptionists transcribe the information. After quality review is complete, the transcribed files can be imported into the provider’s EMR system.
EMRs will become more sophisticated with the development of DRT or discrete reportable transcription. With this, providers can continue the method of dictation and transcription instead of using EMR templates. DRT will directly interface the dictated patient information into the appropriate EMR section. Once DRT technology is in place, the returned transcription can be integrated into the EMR system – each piece of data will be sent to its exact location within the EMR.
