Below are a few examples to make specific parts of medical charting more clear. These were from content that I developed for my residents, but that I thought I would share with a broader audience. These examples are brief, specific, concrete, and geared toward my specialty of emergency medicine. However, the principles that these examples illustrate should help a medical professional make more clear documentation, regardless of specialty.
Take these examples as illustrations of principles, not as the only good way to chart – certainly every professional will apply the same principles a bit differently.
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“re-assess”
I see this frequently as your plans in your charts.
What does “re-assess” mean?
When the plan ends with ”re-assess” you’re only saying that you’ll check on the patient. That’s it. Beyond the re-assessment, you’re saying there is no plan. So basically, you’ve got part of a plan.
Consider the alternatives in the following style that we’ll call “if-then”:
“Will re-assess. If feels better after medication, then will discharge home.”
“If stable gait on re-assessment, then will discharge".
“If labs, EKG, and CXR negative, then will admit to obs for cardiac monitoring.”
These show that you’ve thought through a plan, not that you are going to make up a plan later. Being able to put together a plan and demonstrate it is a key part of clinical medicine. Get into that practice now.
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Show what you mean.
A few well-placed details can sometimes tell the whole story. Choose your details carefully.
Consider this example of a patient you suspect is withholding some pertinent details:
“Avoidant” --> this sounds like you’re placing judgement. Someone could ask how you know they’re avoidant.
“Does not answer some of my questions. Answers other questions without difficulty. Avoids eye contact.” --> This shows there could be something details the patient is not telling you.
You certainly cannot describe every detail. However, when there is an important point for you to make, think on what the right details are and show those details.
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Pain is a subjective thing.
Patients can certainly complain that they have a lot of it.
If a question comes up days, weeks, months later, all you will have to tell your side of the story is your chart. Make sure it shows the important, objective details as well as possible.
For example, a patient in “pain”:
“Says she is in pain, but appears comfortable.” --> this sounds pretty subjective.
“Says she is in pain, but is laying on her side, propped up on her elbow, on her phone and giggling.” --> maybe they are in severe pain, but the picture you paint looks very different.
Just show the key details and they will speak for themselves.
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If you’re interested in learning more about improving the clarity of your medical charting for better clinical communication and medicolegal defensibility, check out my book: The Handbook of Medical Charting
