Documentation of Dual Sensory Impairment in Electronic Medical Records.
OBJECTIVE
To examine the documentation of sensory impairment in the electronic medical records (EMRs) of Veterans with both hearing and vision losses (dual sensory impairment [DSI]).


METHODS
A retrospective chart review of the EMRs of 20 patients with DSI was conducted. Providers' documentation of the presence of sensory impairment, the use of assistive technology during clinical appointments, and the content of notes mentioning communication issues were extracted from each chart note in the EMR for the prior 6 years.


RESULTS
Primary care providers documented DSI in 50% of EMRs, vision loss alone in 40%, and hearing loss alone in 10% of EMRs. Audiologists documented vision loss in 50% of cases, whereas ophthalmologists/optometrists documented hearing loss in 15% of cases. Examination of two selected cases illustrates that care can be compromised when providers do not take note of sensory impairments during planning and provision of clinical care.


CONCLUSIONS
Sensory impairment is poorly documented by most providers in EMRs. This is alarming because vision and hearing affect patient-physician communication and the use of medical interventions. The results of this study raise awareness about the need to document the presence of sensory impairments and use the information when planning treatment for individuals with DSI.
Speech, Language, and Hearing Sciences, University of Connecticut, Mansfield. Brittney.Dullard@uconn.edu.
Brittney
B
Dullard
National Center for Rehabilitative Auditory Research, Portland VA Medical Center, Portland, Oregon.
Gabrielle H
GH
Saunders
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D003142:Communication; D004282:Documentation; D057286:Electronic Health Records / Q000458:organization & administration*; D034381:Hearing Loss / Q000453:epidemiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology; D019987:Persons with Visual Disabilities / Q000706:statistics & numerical data*
Electronic medical records; Hearing impairment; Interdisciplinary communication; Sensory disorders; Vision impairment