What is Relevant in My Chart?

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: 

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

Just Show Me What You Mean

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

Critical Thinking, Questioning Yourself, and Clinical Medicine

 

What is critical thinking and how does it apply to these 3 scenarios?

A nurse walks over to communicate a minor, patient inquiry to a physician who is sitting, brow wrinkled, focused, deep in thought, and contemplating the next step in another patient’s care. The nurse interrupts his train of thought, because “protocol says I have to inform the physician when the patient makes these kinds of requests”.

An intern orders hepatic function tests on every patient with abdominal pain regardless of the pain’s exact location, because “that’s how we do it here.”

An experienced physician orders a chest x-ray for every admission even if the patient’s symptoms do not include the chest, because “that’s the way I was trained and that’s the way I’ve practiced it for years.”

*********

We all fall into old, familiar patterns. Most of the time these patterns serve us well. However, following our familiar patterns is occasionally dysfunctional or wasteful, like in the examples above.

A healthy practice is from time to time to question how and why we do things. This will help improve ourselves and the care of our patients. Ask yourself, “Why do I do what I do?” and “Is there another way to do this that might be better?”

Questioning yourself is applied critical thinking. Many, definitions and applications of critical thinking exist. However, one underlying concept is to question the assumptions that are behind your practices. In doing this, you can test your idea. It is as if you run the idea through a mental stress test to see if it withstands the stress. Your practice may very well be a reasonable way to get things done. However, if your practice does not hold up to the stress of a particular circumstance, then maybe you need to revisit how you do things to see where you need to adjust.

Questioning your own processes takes humility and most people do not like the possibility of being humbled by being wrong. However, if you are able to question yourself with honesty, you will improve yourself and your practice.

*********

Applying some critical thinking questions to the above 3 scenarios:

The nurse may ask, ”Is this the best way the protocol should be applied in this situation?”

The intern may ask, “Will the hepatic function tests help in this patient’s case?”

The experienced physician may ask, “Is the pre-admission x-ray necessary in every admission?”

*********

Arguably, the most important part of critical thinking is taking the first step and asking the question. It’s simple in concept, challenging to carry out, rewarding when you do it, and becomes easier with practice.

If you are interested in learning more about critical thinking in medical decision making or other, related topics, please check out my book: A Guide to Clinical Decision Making