Too many times, I’ve heard my colleagues say, “I leave my
chart intentionally vague so that no one can find anything wrong with it” or “I
make my charts generic so that when I defend it the way I want to”.
These strategies can actually their authors open to the
very assaults these strategies are supposed to protect them from.
Your chart is a record of your vision of that patient, of
your side of the patient’s story. The record should stand apart from you. It should speak for itself. A
well-written chart explaining the patient’s story should not need you to
translate it. Ideally from reading your chart, your reader should see the patient
as you saw the patient. Your reader should see the patient so clearly that they
agree with you. The ideal happens rarely, but we should always try to improve.
Here are 3 fictional examples of how being too vague can
potentially get you into trouble.
The drunk:
Your intoxicated patient is now clinically sober. You
discharge him. He trips in front of the hospital and a bus runs him over. At
autopsy his ethanol level is 200. Two versions of your re-assessment are below:
Vague: Clinically sober now.
Specific: Clear speech. Oriented x3. Cooperative.
Calm. Finger to nose normal bilaterally. Walks tandem gait without stumbling.
When someone reviews the case later, do you want your
chart to read vague or specific?
The fracture:
A patient comes into the ER for right leg pain. She is a
nursing home patient with dementia. Your clinical evaluation finds no acute
pathology. You discharge her. 1 week later she comes in for leg pain again. Evaluation
finds a fractured, right femur.
A nursing home assessment from before her initial visit
to you reads: “Contracted, thin extremities bilaterally. Hyperpigmented rash at
bilateral ankles.”
Two versions of your initial exam are below:
Vague: Bilateral lower extremities normal.
Specific: Bilateral lower extremities have no bony
point tenderness, no swelling, no bruising, no deformity.
When someone reviews your chart later, do you want your
chart to be vague or specific?
The stroke:
A middle-aged patient comes in for dizziness. You find no
concerning findings on your evaluation. 2 weeks later, outpatient workup
reveals a posterior circulation stroke. Again, two versions of your exam are
below:
Vague: normal neurological exam.
Specific: Walks on tip toes without stumbling.
Negative Romberg. No nystagmus.
When someone reviews your chart later, which way do you
want your chart to read, vague or specific?
Certainly we could all go into painful detail about every
last detail. But consider:
What are the important parts of the story we want the chart to convey?
What details tell our patient’s story and which are needless?
If you chart with specific and concreter details, your
chart will better protect you whether it’s from a patient complaint, a morbidity
and mortality conference, or a legal proceeding.
Your chart should
stand on its own. You should build it well to protect you. You should not
have to protect it.
If you’re interested in learning more about improving
your medical charting, check out my book: The
Handbook of Medical Charting.
