Friday, October 28, 2016

Omit Needless Words AKA A Longer Chart is Not Necessarily a Better Chart





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

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