Brief Examples of Clear Charting

 

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

Treat the Patient Not the Number – A Short, Nuanced Perspective on a Traditional Teaching

 

 

 

 

Traditional clinical teaching tells us to treat the patient, not the number. 

At face value, you could interpret this old teaching as “only treat if there are symptoms”. When applying this teaching, we should include some nuance, namely see how the number fits into the big picture.

Good examples include abnormalities in asymptomatic patients that may not be causing a problem right now, but have consequences in the future. Such abnormalities could include: 

• Elevated Hemoglobin A1c 

• Decreased glomerular filtration rate 

• Elevated blood pressure

In an asymptomatic patient, these types of measures are analogous to someone walking towards a cliff’s edge. They are not falling yet. However, the closer they get to the edge the more at risk they are of falling.

When you take the big picture into account, you understand “the number” in the context of the overall, clinical situation. So what is this big picture then? The big picture includes information from the history, physical exam, test results, response to treatment, etc. These are like pieces of a puzzle that fit together  to make the big picture     

Without this greater context, ”the number” can have many different meanings, and can lead you down many, different paths.

You can certainly treat “the number”, but you should do so as part of the big picture that is the patient. 

If you are interested in this and further topics regarding clinical decision making, please check out my book: A Guide to Clinical Decision Making 

 

 

All Your Tests Are Negative. Now What? - A Lesson On Thinking A Step Ahead

You’ve ordered a slew of tests for your patient. You hope that one of them comes back positive, giving you guidance for the next step in the patient's care. However, your tests all come back negative, leaving you wondering what to do next.

This is a common scenario whether you work inpatient, outpatient, or a combination of both.

Most of the time, it’s easy to know what to do if the tests are positive. It’s much harder to decide what to do if the tests are negative.

We cannot discuss every single scenario, but it’s important to bring up the following concept:

When you order a test, consider what you will do if the result is negative.

Do this and you find yourself one step ahead in many clinical scenarios.

Ask yourself questions like:

·         Should I expand my differential diagnosis?

o   If so, what other diagnoses should I check for?

o   If not, am I sure that I have enough information to proceed with treatment?

·         If I need more information, how will I get it?

o   More tests? more History? More physical exams?

Experienced physicians often get to the point that they internalize these processes. However, even experienced physicians can still get stuck when they unexpectedly get negative test results. To be more ready to adapt to these situations, it is good practice for all physicians, from brand new to well-seasoned, to  explicitly ask themselves what their next step will be if the tests they order are negative.

Clinical practice is a tricky thing, and events do not follow the textbooks and guidelines. If you think a step ahead and plan out the next steps for when your tests are negative, you will be more ready when your tests results are unexpectedly negative.

If you are interested in learning more about this and other topics in clinical decision making, check out my book A Guide to Clinical Decision Making.

Cultivating Clinical Acumen Through Mindful Experience

We have probably all seen a senior clinician who just knows. They have that 6^th sense that allows them to navigate a difficult, complex patient case with ease. They just seem to do the right thing at the right time, whether it is making a diagnosis or balancing a complex treatment plan with several competing factors. They have clearly developed clinical acumen.

 I have often heard senior clinicians bemoan that their juniors do not have clinical acumen. However, I’ve rarely heard any of them explain what clinical acumen is, let alone how to acquire it. Some clinicians speak as if clinical acumen is something that we are just supposed to intuitively understand, without explicit guidance. I disagree.

In my experience with bedside teaching, I have found that teachers can cultivate clinical acumen in their trainees.   

What do we mean by clinical acumen? I think this definition will suffice: the ability to navigate a clinical situation effectively and efficiently. 

So how does a clinician learn to navigate a clinical situation effectively and efficiently?

By going through clinical experiences mindfully and actively try to learn from them.

When trainees go through our experiences mindfully, they learn faster and develop clinical acumen more quickly.  

How can they be mindful? One, simple way is to have trainees analyze recent, clinical experiences and then ask them questions such as:

• What might they have done differently?
• What could they do to make things go smoother next time?
• If a variable changed, how would they have managed the situation differently?

By answering questions like this, the trainees run thought experiments, mental simulations that allow them to test ideas and plan for future situations. The results of these thought experiments help them prepare for similar situations in the future. By encouraging trainees to analyze these experiences in this way, we allow them to learn without having to be in every possible scenario. 

A trainee can do such an analysis themselves, and I encourage mine to do so. However, I tend to ask questions like the ones above during a patient presentation, when making decisions on patient care, and when debriefing after treating a patient. When the experience is more fresh, I find that there is better learning. When I have brought trainees through this process often and consistently, they start developing navigating clinical situations well very quickly. With these kinds of teaching processes, I have seen even very junior trainees start to develop acumen in just a few short weeks.

If you want to learn more about this and other clinical decision making processes, you can check out my book: A Guide to Clinical Decision Making