I read one of my resident’s charts. I brimmed with pride.
“On re-assessment, patient now laying in bed, legs crossed,
playing on phone, giggling, asks ‘can I go home now?’”
I guess the pain was gone. The patient was a vague
recollection to me, but by that sentence, I could see the situation as if I was
there.
In a chart, I don’t ask for flowery prose that drones on and
on. I ask for simple, straight-to-the-point illustrations of what happened.
When in doubt, use simple words, and paint a picture of
whatever it is that you see. This is the clearest communication and the
clearest charting. Pinpoint the handful of key details that prove your point
and describe them in simple, straightforward terms.
In modern medicine, time is short but we still have to to
chart accurately. We must balance presenting a clear picture to our reader,
while respecting their time and your own. Sometimes a clinician or their scribe
gets caught up in sounding smart and
using language that is overly technical and needlessly wordy, making the chart
virtually opaque. Other times, a clinician can be so brief they are opaque.
Simple, plain language will usually be the safest fallback when you are unsure
of what to write.
Consider a few examples:
An asthmatic patient:
Opaque: “Appears to be dyspneic”
Simple wording: “Leaning forward. Retracting. Even
responding yes/no makes her feel worse”.
A decubitus ulcer:
Opaque: “Ulcer on sacrum unstageable”
“Sacral ulcer, approximately 3 fingerbreadths diameter,
covered in dark material, no visible bone, no visible muscle, no bleeding.”
A kidney stone:
Opaque: “In discomfort”
“Grimaces constantly, frequently shifting stretcher”
Certainly, we do not have time to go into every detail of
of the history and physical. However, we should think about what the key
aspects of the chart are and focus on using simple words to illustrate
those details. This will go a long way towards making your charts more clear,
and more effective at communicating your point. Simple language will mean that
anyone will understand the picture you paint: nurses, medical students, other
clinicians, an attorney, a jury, etc.
Modern medical charting systems have enough flaws. Your
writing or should not be one of them.
If you are interested in learning more about how to write
your medical charts in a clear and efficient manner, check out my book: The
Handbook of Medical Charting
