A “perfectly good word?” Use of the terms “resilience” and “recovery” in progress notes for patients with post-traumatic stress disorder

Tuepker A, Zickmund S, Nikolajski C, Post L, Hahm B, Butler J, Weir C, Hickam DH. A “perfectly good word?” Use of the terms “resilience” and “recovery” in progress notes for patients with post-traumatic stress disorder. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 17; National Harbor, MD.

Related HSR&D Project(s)

• HIR 09-001 – Consortium of Healthcare Informatics Research: Document Quality and Challenge Evaluations
• HIR 09-003 – Consortium for Healthcare Informatics Research: PTSD

Objectives: For Veterans with PTSD, a variety of clinical interventions can improve their symptoms and functioning. "Resilience" and "recovery" are two terms that have been advocated as measures of patient improvement. We studied the use of these terms in progress notes written by VA clinicians who provide care for PTSD. Methods: We conducted 28 semi-structured interviews with providers at five different VA sites. Each provider was asked to explain the terminology used in 1-2 progress notes written after seeing a patient with PTSD. Interviews were transcribed verbatim and qualitatively analyzed using a directed coding approach. Transcripts were coded by two experienced qualitative researchers who double-coded a subset of transcripts to enhance reliability. Results: No respondent reported using "resilience" in a note under review. Of 27 participants who answered questions about general use, 11 never used it in notes, and 14 described their use of the term as rare. Preferred alternatives included "coping," "progress," "improvement," "skills," "resources," "development," "stability" and "growth," as well as descriptions of specific protective factors. Few providers expressed conceptual difficulty with the concept. Two providers reported using "recovery" in a note under review. Of the 24 who answered questions about general use, 19 reported using it in their notes, again with frequent qualifications. Preferred alternatives included "improved functioning," "improved quality of life," "decreased/resolved symptoms," and "journey." Providers shared uncertainty about the term's meaning, or expressed skepticism regarding its applicability to PTSD. Professional training, prior experience with substance abuse treatment, and current VA initiatives to embrace a Recovery Model in mental health were cited as influences on word choices. Providers also acknowledged concerns about the impact that their use of "recovery" might have on patients' eligibility for disability claims. Implications: The concept of resilience is well understood but rarely chosen to record information about patient functioning. The term "recovery" is more widely used but less clearly or consistently understood. Impacts: Clinical terms used in the literature about PTSD may have limited applicability to documentation of patient status in progress notes. A wide range of other terms are used to denote patient responses to treatment interventions.