In Defense of the Maligned Dot Phrase

I’m a big fan of fellow pediatrician blogger Bryan Vartabedian’s 33 Charts. While I spent a few years at Texas Children’s Hospital, our paths never crossed, and that’s a shanda because Dr. V says smart things in an entertaining way. If you don’t know his work, you should.

Recently, Bryan referenced his post titled “Within Normal Limits.” In this piece, he notes that back in the olden days (before electronic health records, that is), doctors would often document physical findings as “WNL” which was meant to indicate to the reader that all findings were within normal limits. As a card-carrying member of the WNL Writer’s Group back when I was documenting physical exams on paper, I would translate WNL as “All the stuff I checked for was pretty OK” or “Nothing to see here so let’s move on, shall we?”

Dr. V writes that most physicians (especially those in training) occasionally were a bit lax and might not have examined their patient as thoroughly as they should have. When a resident doctor wrote “Skin: WNL” despite an impressive rash or series of nevi, supervising clinicians might enquire about the true meaning of those three letters. Perhaps, they would ponder aloud, the abbreviation meant “We never looked”. Ultimately, WNL slowly went the way of the Model T and nurses’ white caps as documentation requirements to get paid or prove quality or defend against a malpractice claim necessitated much more specificity than WNL.

I’m with the good doctor so far. But then he compares the willy-nilly use of WNL to an EHR’s dot phrases (or as popular software vendors call them, SmartPhrases or Autotexts). Dot phrases allow a physician to type a few characters but then generate a lot of text. For instance, I might create a dot phrase that allows me to type “.skinwnl” and then get the statement “A full-skin exam was performed. Skin was of normal texture, color, and turgor. There were no rashes, lesions, or nevi.” That’s pretty cool, right? Right!

Despite the coolness factor on first blush, I see where Dr. V is coming from. Did you really perform a full-skin exam, or did you more likely pull up the child’s shirt to glance at his abdomen and back, not looking anywhere else, as you might do when evaluating a patient for a URI? Sounds pretty WNL to me. It’s perfectly fine to do a limited exam of the skin, but it’s not ok to document an exam you never really performed.

So, are dot phrases really “WNL on crack” as Bryan writes? I’ll agree that they can be. But like virtually every instrument in our clinical armamentarium, EHR efficiency tools are only as good as the way they are used. A scalpel can be used to save a life or end a life; we depend on the user of said scalpel to make the right choices! I won’t be as melodramatic when referencing dot phrases, but I surely believe that dot phrases can be a great documentation aid.

Here are some tips and tricks to consider when using and creating dot phrases. If you follow these suggestions, you’ll likely stay on the good side of The Force.

• Create multiple versions of the same phrase with differing levels of specificity and breadth. Imagine having five different versions of a skin exam. Assuming individual doctors can create their own (which is typical EHR functionality), you can name these phrases in a way that means something to you (e.g. skinuri – for a very brief skin exam associated with a visit for a URI complaint, skingi – for a focused skin exam associated with complaints of constipation or diarrhea, and skineczema – for a skin exam associated with typical mild eczema symptoms.)
• Create phrases that bring in discrete data from the EHR. Most commercial EHRs let you document data found in various places in the record. While these phrases can contribute to note bloat by bringing in voluminous, unnecessary data, they can also be used for good. For example, a phrase such as lastinr or tmax24hr can bring in very specific data and might even fit nicely in a sentence structure: .fname’s last INR result was .lastinr.” I personally much prefer these prose-type phrases than dot phrases that display tables and long lists.
• Use phrases sparingly and intelligently. What do I mean by this? I like to say that structured documentation is great when structured documentation is great. Same goes for dot phrases. Use phrases when they fit into a solid, well-written H&P or progress note, but avoid them in parts of your note where “the story” matters. Dot phrases are fabulous in the physical exam and review of systems. They’re not welcome in most parts of the assessment and plan. Type or use voice recognition where the personal physician touch is essential.

Overall, I’m a fan of dot phrases. But we must use them to help us create documentation that assists clinicians as they care for patients. If your goal is to have the longest progress note in the hospital, go nuts with dot phrases to your heart’s delight, but please oh please don’t admit patients to hospitals with which I’m associated.