Females Shouldn't Have Male Genital Discharge - A Lesson on Macros in Charting

Years ago, I had a bright, efficient resident who was very adept at using macros in his charts. His charting looked complete and detailed at first glance. I had made it a habit to skim through each section of each resident’s note to make sure the gist of the patient’s story was complete to the best of our understanding. I thought I would not have to worry about this resident.

Then while skimming a chart I saw this for a female patient: “penile discharge – negative”

I went to him and talked to him about it. He’d been using the same macro on all his patients and then customizing them. I told him he should be more careful. We had a talk about having his chart internally consistent and why internal consistency made his chart more credible… and how a more credible chart means a more credible doctor.

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Imagine if you had a chart with an assault victim, you mentioned bruising in the HPI and you forgot to adjust your macro ROS and it still said “no bruising”. The following questions would likely pop up:

·         Which part should your reader believe?
·         Would your chart be believable at all?
·         Would you look sloppy?
·         Would you seem believable? 
 

Now imagine that hypothetical chart in an M &M conference, at a deposition, or in a court. Suddenly your oversight makes you look real bad.

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I think macros are fine tools. However, you have to be careful using them. Macros can certainly speed you up, especially when it’s busy and your charting system is slow. However, if you’re not careful they can hurt you. A power saw is a good example of such a tool. It cuts fast, but can cut you badly if you’re careless. 

Be careful when using a power saw and be careful when using macros. Both can hurt you when you’re not paying attention.

If you are interested in learning more about medical charting, please check out my book: The Handbook of Medical Charting

Context Matters: The Time I Sent Home the Patient With the Elevated Troponins

Note: I’ve changed some of the details of this story so that it does not match the real patients I based this story on.

I saw a patient in the ER for complaints of generally not feeling well. She was in her 60’s with diagnoses of heart disease and HTN. That was all I was able to tell. She did not speak English, and with the assistance of family members and a translator, I found that she had poor memory as well. 

Her exam showed that she was mildly hypertensive, comfortable, and with normal heart, lung and abdominal exams. 

Her EKG showed signs of LVH, but was otherwise unremarkable. 

Her troponin was 2. Other labs and CXR were normal. 

Here was a slam dunk admission.

I ordered that hospital’s protocol treatment for NSTEMI and called the cardiologist. The cardiologist agreed to admission.

I went back to explain the findings and plan for admission the patient and her family. I mentioned heart damage, and they told me that she had that recently at another hospital for some kind of heart problem. I contacted that hospital to get more information. The other hospital admitted her for an NSTEMI, troponin peaked at 8, and trended down to 3 by time of discharge. Discharge wss 2 days ago. I updated the cardiologist who recommended repeat troponin and EKG in 3 hours. She would be clear from a cardiac perspective if there were no changes.

I sent her home later that shift with unchanged troponins.

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One lesson that I try to emphasize in my junior trainees is that context means a lot in clinical medicine. One data point is rarely enough to make a decision. We need to know more of the story, but unfortunately most of the time we only get a snapshot. 

When you get an abnormal result, put it in the bigger context. It will usually make more sense and the way forward will be clear. 

When possible, try to get the bigger context. That can come in the form of old records (like it did in my situation), further history, further testing, or further clinical exam. Collect more data in an intelligent way, try to put it together, take a step back and try to make sense of it. There is most likely a pattern there that will guide you to the answer.

If you are interested in this or other topics in medical decision making, check out my book: A Guide to Clinical Decision Making.