Guest post: Distressing terminology

By Howard Rodenberg, MD, MPH, CCDS

Our coding director recently retired, but before she did, she left one small but significant parting gift.

Our department is no longer known as Clinical Documentation Improvement. We are now Clinical Documentation Integrity, and that one-word difference represents a significant change that better reflects the entire gamut of what we do. Fortunately, we can still use the initials CDI, which means we don’t need to change out the monogrammed towels.

Words clearly matter, and even changing one small item can profoundly change the meaning of a simple phrase. Changes in word order can do the same: “Grandma, let’s eat,” and “Let’s eat Grandma” mean two different things—one likely a festive holiday meal, the other is dinner with the Donner Party. In CDI, words are the essence of what we do as we rely on physician documentation, the words that synthesize the physician’s cumulative experience and judgement into a diagnosis, to accomplish our goals.

We’ve recently started a clinical validation process, and found a number of outcomes we didn’t expect. (In the interest of withholding the juicy stuff, I’m not going to share it all. Hopefully, we’ll get our poster accepted for the ACDIS Conference, and we want you to drop by and say hello.) I do want to note, though, that one of our biggest issues has to do with the clinical description of illness, and why there’s got to be a better word for clinicians to use to describe the patient’s physical appearance than “distress.”

Distress is a ubiquitous word in the medical record. Patients are most often recorded to be in none, mild, moderate, or severe distress. (This is the origin of the stereotypical physician note: A LOL in NAD, or a little old lady in no acute distress.) But if you think of how distress is applied, it really suggests an extreme. This thought is borne out when looking at the most common definitions of the term. The Collins English Dictionary notes that, “Distress is a state of extreme sorrow, suffering, or pain; or the state of being in extreme danger and needing urgent help.”

However, this definition of distress as being on the edge really doesn’t play out clinically. Patients may be sick, acutely ill, or injured, but not be in acute distress. I can feel rotten, be uncomfortable, look miserable, and even be aesthetically displeasing. I might require hospitalization for any of these reasons, but I still might not be in acute distress. Plus, distress is an inherently subjective term. Being in distress from pain or existential angst is a different kettle of fish from hypotension and shock.

The definition of distress implies being on the knife-edge, and while our patients may be sick hopefully we’re there before they lurch towards the cliff. And even if we like the term, it’s hard to figure out what we mean by mild, moderate, or severe distress. Is there a difference between “mild” and “severe” extreme danger? Is it like being attacked the three crocodiles versus 13? It stands to reason that there’s got to be some better way to describe those patients with serious illness or injury when clinical intuition raises red flags before the reaper stands by the door. So, if medicine espouses distress as a term of extremes, is it any wonder that genuinely ill patients with serious diagnoses may be reported as “NAD?”

Because we use it as an indicator of imminent demise, distress is a word that gets attention. It suggests a certain severity of illness that helps support the documentation of more complex diagnoses. I can understand our reliance on it. But I think there’s room in the lexicon for better terminology.

What might we do instead? Fortunately, there are a host of synonyms for “distress,” each with its own connotations. Here’s a list from yourDictionary.com:

Worry, anxiety, perplexity, misery, sorrow, wretchedness, pain, suffering, agony, anguish, dejection, irritation, vexation, ache, heartache, dolor, ordeal, desolation, mortification, affliction, discomfort, trouble, woe, torment, torture, shame, grief, embarrassment, disappointment, tribulation, pang, agony, anguish, suffering, ache, straits, danger, trouble, adversity, anger, difficulty, disaster, poverty

Clearly, some of these terms are more appropriate than others. (My new goal is to work “wretchedness” into an ED note.) But the sheer number of alternate terms suggest that one can describe different degrees of acuity other than using the limiting term “distress.” When I work clinically, I’ll say that the patient looks ill, seems uncomfortable, appears unwell, or feels miserable to indicate the patient’s need for admission without the extreme implications of using the word distress.

As CDI specialists, we need to find better terms to describe the clinical appearance of illness. And in our “point and click world,” it becomes incumbent to work with our IT colleagues to build terms into the EHR that offer physicians more varied, accurate, and nuanced choices to document what they see and embody the “integrity” of our endeavors.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com or follow his personal blog at writingwithscissors.blogspot.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.