Spoken vs Written English - The Writing Exercise

This post is another writing exercise. We’ll be applying lessons I’ve shown you from previous posts (Omit Needless Words, Pay Attention to Your Formatting, and Written vs Spoken English) to a sample, fictional chart.

This post should be helpful to those who either use voice to text software or scribes who tend to transcribe verbatim.

Follow instructions as with the previous writing exercise posts:

1.       Copy and paste the sample to a word processor.

2.       Make your edits using the writing principles.

3.       Compare your answer to the possible answer at the bottom of the post.

I wrote the sample history of presenting illness as if I was dictating verbatim into a microphone. Here it is:

The patient is a 28 year old male with a history of obesity and asthma. He comes in today via EMS after a motor vehicle accident. He was the restrained driver in a motor vehicle accident where he rear ended the other car at what he estimated to be 15-20 miles per hour. He denied LOC. He denied head strike. He denied memory difficulty. He denied drug or alcohol use in the past 24 hours. He denied chest pain. He denied extremity pain. He denied dizziness. He said that he was distracted for a moment returning a text when the accident happened. He said the front end of his car “was totaled”. He said he was able to walk afterwards. EMS report confirms that he was ambulatory at the scene. EMS report also confirms extensive damage to the front of his car.

This may work well for spoke English, but it’s poor written English. It’s a jumble that we can clean up with a little bit of work.

Work on it and then scroll down. I've shown you one path (certainly others exist) to a more efficiently-written version of this HPI. 

First, let’s pare the HPI down to essential words. I’ll highlight what’s (arguably) needless. Repetition is an easy first target for cutting out needless words. What words does the story need to drive itself forward?

The patient is a 28 year old male with a history of obesity and asthma. He comes in today via EMS after a motor vehicle accident. He was the restrained driver in a motor vehicle accident where he rear ended the other car at what he estimated to be 15-20 miles per hour. He denied LOC. He denied head strike. He denied memory difficulty. He denied drug or alcohol use in the past 24 hours. He denied chest pain. He denied extremity pain. He denied dizziness. He said that he was distracted for a moment returning a text when the accident happened. He said the front end of his car “was totaled”. He said he was able to walk afterwards. EMS report confirms that he was ambulatory at the scene. EMS report also confirms extensive damage to the front of his car.

 

 Now with some needless words taken out:

A 28 year old male with a history of obesity and asthma comes in via EMS after a motor vehicle accident. He was the restrained driver where he rear ended the other car at what he estimated to be 15-20 miles per hour. He denied LOC, head strike, memory difficulty, drug or alcohol use in the past 24 hours, chest pain, extremity pain, dizziness. He was distracted for a moment returning a text when the accident happened. He said the front end of his car “was totaled”. He was able to walk afterwards. EMS report confirms that he was ambulatory at the scene and extensive damage to the front of his car.

 

We’ve tightened our HPI up a little bit. Now let’s format it by separating out some logical sections.

One section could be a chief complaint with a little bit of context. Another section could be a review of pertinent systems. Yet another section could be confirmatory information from EMS.

I’ll highlight them in different colors and then separate them.

A 28 year old male with a history of obesity and asthma comes in via EMS after a motor vehicle accident. He was the restrained driver where he rear ended the other car at what he estimated to be 15-20 miles per hour. He denied LOC, head strike, memory difficulty, drug or alcohol use in the past 24 hours, chest pain, extremity pain, dizziness. He was distracted for a moment returning a text when the accident happened. He said the front end of his car “was totaled”. He was able to walk afterwards. EMS report confirms that he was ambulatory at the scene and extensive damage to the front of his car.

Our answer:

A 28 year old male with a history of obesity and asthma comes in via EMS after a motor vehicle accident. He was the restrained driver where he rear ended the other car at what he estimated to be 15-20 miles per hour. He was distracted for a moment returning a text when the accident happened. He said the front end of his car “was totaled”.

He denied LOC, head strike, memory difficulty, drug or alcohol use in the past 24 hours, chest pain, extremity pain, dizziness. He was able to walk afterwards.

EMS report confirms that he was ambulatory at the scene and extensive damage to the front of his car.

Now it’s much easier to read.

Are there other ways to separate and organize the information? Yes, but this is just to demonstrate the process. Each person will use these tools a little bit differently.

The important concepts to remember are to omit the needless words and to organize your thoughts in a logical manner on the screen.

To learn more about clear and effective communication in medical charting, please check out my book: The Handbook of Medical Charting