A common trap you can fall into is mistaking a longer
chart for a better chart. Many people fall into the trap of adding more and
more details. Perhaps they think they must show the patient’s complete story,
or that they have to draw out every aspect of the story to make the story
clear, or that spelling out all the details will defend them better
medico-legally.
They are all wrong.
Classic teaching for good writing is to omit needless
words. You should write enough detail to communicate the pertinent part of your
patient’s story, no more, no less. You should add needed details. Leave out the
needless ones, ones that get in the way. At a certain point, your story gets
lost in these other details. Adding those useless details starts to make your
communication worse.
Writing in copious detail, by itself, is not better
writing. Other fields have a saying, “More is not better, better is better.”
Through your chart you are communicating with another
professional. You want your communication to be clear. Ok, this sounds
intuitive when you read it, but how many times a day will you read a chart and
think, “huh?”, or “what did I just read?”, or “that made no sense”? Take the
reader’s perspective when you start writing. Another person is going to read
this chart when you are done, so make it easy to read.
Another issue comes from not having a clear idea of what
you are trying to communicate. If this is your problem, and you’re writing down
every detail in the hopes that someone else will figure the patient’ s story
out, then your problem is not in your writing. Before you begin writing, you
have to have at least a rough idea of what you’re trying to communicate.
I’ll use the following example to illustrate some concepts
of omitting needless words:
History of Presenting
Illness:
Mrs.
Leg is a 55 year old female who comes to clinic with one week of right leg
swelling. Symptoms started suddenly. The swelling is painful. She now walks
with a limp. Walking makes her pain worse. She has no trauma, takes no
anticoagulation, and no previous, similar symptoms. She has HTN for which she
takes amlodipine. She had a cholecystectomy about 15 years ago without
complications. No other surgery. She smokes. She has no recent travel, hormone
therapy, chest pain, abdominal pain, back pain, SOB, cough, dyspnea, orthopnea,
palpitations, dizziness, lower extremity numbness, lower extremity weakness,
skin color changes, itchiness, bruising, dysuria, joint pain, fever, no
bleeding tendencies, and no family history of thromboembolism. She estimates
she walks about 1 mile every day, until her pain started about one week ago.
Review of Systems:
General:
no fever
Cardiac:
no chest pain, no palpitations, right leg swelling
Respiratory:
no cough, no dyspnea, no orthopnea
GI:
no nausea, no abdominal pain
GU:
no dysuria
Neurological:
no extremity weakness, no extremity numbness, no dizziness
Hematologial:
no bleeding tendency
MusculoSkeletal:
no joint pain, no joint swelling
Past Medical History:
Hypertension
Past Surgical History
Cholecystectomy
15 years ago
Social History:
Smoke
½ pack of cigarettes per day
Married
Physical Exam:
General:
comfortable, no acute distress
Cardiology:
RRR, no murmur, DP pulses present and equal bilaterally, capillary refill less
than 2 seconds in all toes. Diffuse right calf tenderness. Negative homan’s
sign. Right calf 35 cm in diameter. Left calf 31 cm in diameter.
Respiratory:
no accessory muscle use, CTAB
GI:
Soft, nontender, no masses, no guarding, normal bowel sounds
GU:
No CVA tenderness
Musculoskeletal:
FROM to bilateral lower extremities. No bony tenderness to bilateral hips,
thighs, knees, legs, ankles, or feet. No ligamentous laxity to bilateral knees.
Soft tissue tenderness to the posterior right calf. No soft tissue tenderness
to the right thigh, left thigh, or left calf.
Neurological:
5/5 strength in bilateral feet, sensation to light touch present and equal in
bilateral lower extremities. Negative straight leg raise bilaterally. Deep
tendon reflexes present and equal to knees and ankles bilaterally.
Skin:
no jaundice, no pallor, no lower extremity petechiae, no lower extremity wound,
no lower extremity bruising, no lower extremity erythema,
Psychiatric:
good historian, logical thought process, clear speech.
Assessment and Plan:
Mrs.
Leg is a 55 y/o female with a hx of HTN and cholecystectomy 15 years ago. She
comes for evaluation of one week of right leg swelling and pain. She denied
trauma or previous, similar symptoms. She has no recent travel history or
hormone therapy. Her physical exam reveals right calf 35 cm in diameter, left
calf 31 cm in diameter, and right calf tenderness diffusely. However, she had
negative Homan’s sign. Mrs. Leg’s differential diagnosis includes deep vein
thrombosis and Baker’s cyst. I will arrange for a Doppler ultrasound to assess
for possible DVT. I will prescribe analgesia for pain.
Several parts of this example show needless words, and
details that get in the way of telling the main idea that you want to convey. Several
times the chart repeats identical information. Did the repetition make the
conclusion more clear? Did it communicate the conclusion more effectively? Did
it make reading the chart easier? If it does not, then repeating the
information is a waste of time for both you and your reader.
In this case, the end is a good point to start. The
conclusion is: “Mrs.
Leg’s differential diagnosis includes deep vein thrombosis and Baker’s cyst.” This
whole chart has been building up to this.
Is the recap in the assessment and plan useful? Yes. This
kind of a recap is useful if preceding aspects of the chart did not do their
job and you have to clarify to your readers what you are trying to
communicate. It’s a reasonable recap that might lead some readers to ask, why
even bother with the rest of the chart? That is a very good question.
The conclusion is a good focus point. What aspects of the
patient’s history point towards a DVT or Baker’s cyst? We’re trying to show our
readers why we think this, right?
Let’s now look at the history of presenting illness a bit
closer:
“Mrs.
Leg is a 55 year old female who comes to clinic with one week of right leg
swelling. Symptoms started suddenly. The swelling is painful. She now walks
with a limp. Walking makes her pain worse. She has no trauma, takes no
anticoagulation, and no previous, similar symptoms. She has HTN for which she
takes amlodipine. She had a cholecystectomy about 15 years ago without
complications. No other surgery. She smokes. She has no recent travel, hormone
therapy, chest pain, abdominal pain, back pain, SOB, cough, dyspnea, orthopnea,
palpitations, dizziness, lower extremity numbness, lower extremity weakness, skin
color changes, itchiness, bruising, dysuria, joint pain, fever, no bleeding
tendencies, and no family history of thromboembolism. She estimates she walks
about 1 mile every day, until her pain started about one week ago.”
Ask yourself, “what do I need to focus on to show that
I’m worried about DVT or Baker’s cyst?” Everything else is extra. It just gets
in the way. Do you really need the highlighted phrases below to focus your
reader on the conclusion you will be getting to? Or did they just get in the way?
Mrs.
Leg is a 55 year old female who
comes to clinic with one week of right leg swelling. Symptoms started
suddenly. The swelling is painful. She now walks with a limp. Walking makes her pain worse. She has
no trauma, takes no anticoagulation, and no previous, similar symptoms. She has HTN for which she takes
amlodipine. She had a cholecystectomy about 15 years ago without complications.
No other surgery. She smokes. She has no recent travel, hormone therapy, chest
pain, abdominal pain, back
pain, SOB, cough, dyspnea, orthopnea, palpitations, dizziness, lower extremity numbness, lower extremity
weakness, skin color changes, itchiness, bruising, dysuria, joint pain, fever, bleeding tendencies,
and no family history of thromboembolism. She estimates she walks about 1 mile
every day, until her pain started about one week ago.
You can certainly build a case for your conclusion
without the parts that I highlighted. These other facts just get in the way.
They do not add to the conclusion you are trying to convey.
You can put many of these other facts into the review of
systems section. The review of systems is a good place for facts about the
patient that address other potential diagnoses, demonstrate your thoroughness
for billing purposes, and that you collected but do not add to your conclusion.
The physical exam portion is different from both the
history of presenting illness, and the review of systems. The physical exam
section includes facts that both drive your conclusion forward, and that are
there for other purposes (address other potential diagnoses, demonstrate your
thoroughness for billing, etc.).
I’ve highlighted the parts of the physical exam below
that are not necessary to the conclusion of DVT vs Baker’s cyst, or an
immediately applicable, related diagnosis like pulmonary embolism or
compartment syndrome.
Physical Exam:
General:
comfortable, no acute distress
Cardiology:
RRR, no murmur, DP
pulses present and equal bilaterally, capillary refill less than 2 seconds in
all toes. Diffuse right calf tenderness. Negative homan’s sign. Right calf 35
cm in diameter. Left calf 31 cm in diameter.
Respiratory:
no accessory muscle use, CTAB
GI:
Soft, nontender, no
masses, no guarding, normal bowel sounds
GU:
No CVA tenderness
Musculoskeletal:
FROM to bilateral lower extremities. No bony tenderness to bilateral hips,
thighs, knees, legs, ankles, or feet. No ligamentous laxity to bilateral knees.
Soft tissue tenderness to the posterior right calf. No soft tissue tenderness
to the right thigh, left thigh, or left calf.
Neurological:
5/5 strength in bilateral feet, sensation to light touch present and equal in
bilateral lower extremities. Negative
straight leg raise bilaterally. Deep tendon reflexes present and equal to knees
and ankles bilaterally.
Skin:
no jaundice, no
pallor, no lower extremity
petechiae, no lower extremity wound, no lower extremity bruising, no
lower extremity erythema,
Psychiatric:
good historian, logical
thought process, clear speech.
Quite a bit of data here is superfluous to the
conclusion. Also we can write some of the pertinent details in a more concise
manner.
Musculoskeletal:
FROM to bilateral lower
extremities. No bony tenderness to bilateral hips, thighs, knees, legs, ankles, or feet.
No ligamentous laxity to bilateral knees. Soft tissue tenderness to the
posterior right calf. No soft tissue tenderness to the right thigh, left thigh, or left calf.
Becomes
Musculoskeletal:
Bilateral lower
extremities have normal ROM and no bony tenderness. No ligamentous
laxity to bilateral knees. Soft tissue tenderness to the posterior right calf.
No soft tissue tenderness to the lower extremities otherwise.
Now let’s get back to the conclusion. If you’re
communicating well with the HPI, ROS, and physical exam, then you shouldn’t
have to repeat yourself. Repeating yourself shows you know you’ve done a poor
job communicating via the other parts of the chart.
Mrs. Leg is a 55 y/o female with a hx
of HTN and cholecystectomy 15 years ago. She comes for evaluation of one week
of right leg swelling and pain. She denied trauma or previous, similar
symptoms. She has no recent travel history or hormone therapy. Her physical
exam reveals right calf 35 cm in diameter, left calf 31 cm in diameter, and
right calf tenderness diffusely. However, she had negative Homan’s sign. Mrs. Leg’s differential
diagnosis includes deep vein thrombosis and Baker’s cyst. I will arrange for a
Doppler ultrasound to assess for possible DVT. I will prescribe analgesia for
pain.
Becomes
Mrs.
Leg’s differential diagnosis includes deep vein thrombosis and Baker’s cyst. I
will arrange for a Doppler ultrasound to assess for possible DVT. I will
prescribe analgesia for pain.
By the time you come around to your conclusion, it should
be obvious enough to your reader that spelling the story out again should be a
little painful.
If you’re tempted to write more, focus on writing better.
You should strive for quality writing, writing that clearly shows your
patient’s story. Your quantity should be just enough to get the job done.
Here’s what the same chart would look like with the edits
I’ve made.
History of Presenting
Illness:
Mrs.
Leg is a 55 year old female with one week of right leg swelling. Symptoms
started suddenly. The swelling is painful. She has no trauma, takes no
anticoagulation, and no previous, similar symptoms. She had a cholecystectomy
about 15 years ago without complications. No other surgery. She smokes. She has
no recent travel, hormone therapy, chest pain, SOB, cough, dyspnea,
palpitations, skin color changes, and no family history of thromboembolism. She
estimates she walks about 1 mile every day, until her pain started about one
week ago.
Review of Systems:
General:
no fever
Cardiac:
no chest pain, no palpitations, right leg swelling
Respiratory:
no cough, no dyspnea, no orthopnea
GI:
no nausea, no abdominal pain
GU:
no dysuria
Neurological:
no extremity weakness, no extremity numbness, no dizziness
Hematologial:
no bleeding tendency
MusculoSkeletal:
no joint pain, no joint swelling
Past Medical History:
Hypertension
Past
Surgical History
Cholecystectomy
15 years ago
Social
History:
Smoke
½ pack of cigarettes per day
Married
Physical Exam:
General:
comfortable, no acute distress
Cardiology:
DP pulses present and equal bilaterally, capillary refill less than 2 seconds
in all toes. Diffuse right calf tenderness. Negative homan’s sign. Right calf
35 cm in diameter. Left calf 31 cm in diameter.
Respiratory:
no accessory muscle use, CTAB
Musculoskeletal:
Bilateral lower extremities have normal ROM and no bony tenderness. No
ligamentous laxity to bilateral knees. Soft tissue tenderness to the posterior
right calf. No soft tissue tenderness to the lower extremities otherwise.
Neurological:
5/5 strength in bilateral feet, sensation to light touch present and equal in
bilateral lower extremities.
Skin:
pallor, no lower extremity wound, no lower extremity bruising, no lower
extremity erythema,
Assessment and Plan:
Mrs.
Leg’s differential diagnosis includes deep vein thrombosis and Baker’s cyst. I
will arrange for a Doppler ultrasound to assess for possible DVT. I will
prescribe analgesia for pain.
This is certainly a chart with flaws in its writing. But
cutting out many unnecessary words make this chart shorter, more focused,
easier to read, and better communication. This chart is not more, it is better.
So when tempted to write more, ask yourself are the words
helping to make my communication better. If not, you should leave them out.
To learn more about effective medical charting, check out
my Handbook
of Medical Charting
