Modern medical charting encourages clinicians to fill out as much as possible in a chart. Charting this way is bad communication. Both you and your reader will lose important details in the chart.
For example, a progress note physical exam for a patient admitted COPD who has already been in the hospital 2 days can end up looking like this:
General: Comfortable, no acute distress, reclining in stretcher, holds conversation without difficulty
Skin: No rashes, no jaundice, normal color, capillary refill less than 3 seconds
HEENT: midline trachea, no tonsillar exudate, no stridor, tympanic membranes clear, ear canals clear
Resp: moderate wheezing in all lung fields, air moving equally bilaterally, no accessory muscle use,
Card: regular rate and rhythm, no murmurs, no gallops, no rubs, dorsalis pedis pulses equal, regular and strong
GI: normal bowel sounds, no tenderness in all 4 quadrants, no masses, no fluid wave
MuscSkel: full range of motion to all extremities, nontender extremities, no lower extremity edema
Neuro: cranial nerves 2-12 intact, 5/5 strength in all 4 extremities, deep tendon reflexes equal in knees and elbows
Psych:
awake, alert, oriented to person, place and time, calm, cooperative,
has good insight into his disease, has good memory of his past
hospitalizations
Yes, this was “complete”. But I drowned you out with unnecessary details. Maybe reading this you even forgot that the patient had COPD. This level of detail in every organs system is appropriate in some settings, but in other settings it gets in the way.
You would expect this level of detail in an annual physical or on the
initial admission to the hospital – not in a progress note.
True, certain factors favor this kind of overcharting
including recommendations related to billing, the need to have a
“complete” assessment of the patient, and the design of the medical
record system.
So
how do we focus on what is relevant? You have to answer this question:
Put your focus on details into the patient’s problem. In this case, the patient is in the hospital for COPD – focus on the respiratory findings and go into painful detail on your focus. Certainly you should still add in other findings for completeness, but do not go into painful detail unless it is truly necessary.
What is the patient’s problem?
Put your focus on details into the patient’s problem. In this case, the patient is in the hospital for COPD – focus on the respiratory findings and go into painful detail on your focus. Certainly you should still add in other findings for completeness, but do not go into painful detail unless it is truly necessary.
Here is version of the physical exam above that puts more focus on pertinent details while still covering all the same organ systems:
General: Comfortable, holds conversation without difficulty
Skin: no jaundice
HEENT: midline trachea
Resp: moderate wheezing in all lung fields, air moving equally bilaterally, no accessory muscle use
Card: regular rate and rhythm
GI: normal bowel sounds, no tenderness in all 4 quadrants
MuscSkel: no lower extremity edema
Neuro: 5/5 strength in all 4 extremities
Psych: calm, cooperative
This
shows that you checked the other organ systems to screen for any new,
deterioration, but you focus on the main issue at hand, the patient’s
COPD. This concept applies to other notes such as followup clinic visits, emergency department visits, and urgent care visits.
Overcharting has several, potential downsides:
- By accident, you can chart something wrong or that you did not do. Even if you clarify this later, it puts the integrity of your chart into question. You do not want the integrity of your chart in question whether it is an internal, quality process, an insurance audit, or a legal trial.
- Your chart will take longer to write. We all know that time is valuable and unnecessary charting is a bad use of a clinician’s time.
- Your chart will take longer to read. We should respect the time of the other clinicians who will read your chart the future by not giving them superfluous detail. Their time is better spent on the important facts.
Avoid these problems by thinking about how where you put the detail in your chart by considering the patient and what is going on with them. Cut out the superfluous details and focus on what is important.
Modern, electronic, medical charting has many drawbacks, your charting should not be one of them.
If
you are interested in learning more about medical charting for clear
communication and medico-legal defensibility, check out my book: The Handbook of Medical Charting
