Pay Attention to Your Format AKA Use Paragraphs

As chart writers, we often overlook a medical chart’s formatting. What I mean by formatting is simply how your chart looks, how the words are laid out on the screen in front of you. How a chart looks affects how easily and quickly someone else can read it.

We do not have control over what some parts of our chart will look like. For example, many medical record systems lock us into a particular format for the review of systems and physical exam. The medical record software often controls aspects of the HPI and medical decision making sections as well.

However, most electronic medical record systems allow clinicians some control over the free text sections of the HPI and medical decision making. These parts of the chart contain much of the critical, clinical information. I’ll show you how small adjustments to our prose in these sections can make a big difference in our readers’ ability to quickly understand what we are trying to tell them.

I’m going to demonstrate two related concepts:

1. Separate different ideas.

2. Group similar ideas together.

They are essentially opposite sides of the same coin.

Functionally you end up writing paragraphs. Paragraph writing a skill that we probably all learned early in our education. This skill still applies when we write medical charts.

When you clump all of your ideas together, it’s more difficult to read. Simply making space at the appropriate place makes a huge difference in ease of reading. Reading a complicated history is much easier when you ‘ve divided the ideas into logical paragraphs. The paragraphs don’t (and usually shouldn’t) be lengthy either. You’ll see this in the examples below.

In the following examples the spacing choices could potentially be a little bit different. However, these examples only illustrate the principle. Sometimes we have multiple ways to format that make sense.

Our first example:

The patient is a 57 year old female with a history of hypercholesterolemia and arthritis. She complains mainly of dizziness, nausea, vomiting, and palpitations. Dizziness started about one week ago. The other associated symptoms worsened when her dizziness gets worse. Moving her head triggers her dizziness. She had similar symptoms in the past when she received a diagnosis of vertigo. She has no diarrhea, headache, blurry vision, or loss of consciousness.

Let’s see how breaking this up a little bit can make it easier to read:

The patient is a 57 year old female with a history of hypercholesterolemia and arthritis.

She complains mainly of dizziness, nausea, vomiting, and palpitations. Dizziness started about one week ago. She had similar symptoms in the past when she received a diagnosis of vertigo.

When her dizziness is severe, the other symptoms appear. Moving her head triggers her dizziness.

She has no diarrhea, headache, blurry vision, or loss of consciousness.

Here I separated the background information from the primary complaint. I also separated exacerbating factors, and ROS type symptoms. Making paragraphs allows the readers to focus on different parts of the patient’s story without interference from the other information.

Another example:

CBC, electrolytes, and cardiac enzymes negative. EKG shows NSR, normal intervals, no ST segment deviation, and no T wave inversions. The clinical picture does not fit MI. I discussed the results with the patient. Will discharge to followup with PMD.

When it’s broken up, we get:

CBC, electrolytes, and cardiac enzymes negative.

EKG shows NSR, normal intervals, no ST segment deviation, and no T wave inversions.

The clinical picture does not fit MI. I discussed the results with the patient. Will discharge to followup with PMD.

I separated the results by type, and then led into my conclusion and plan. Hitting the “Enter” button a couple of times made my chart much easier for my reader to read.

Now one more example that’s a little bit more complicated:

A 60 year old female with a history of asthma, HTN, hypercholesterolemia, arthritis, and cholecystectomy comes in with SOB. She has wheezing, dry cough, and chest tightness with cough. Exposure to smoke from a kitchen fire triggered her symptoms. Taking several doses of her albuterol inhaler improved her symptoms mildly. Symptoms feel similar to her asthma. She denied fever, palpitations, chest pain, abdominal pain, nausea, vomiting, and dizziness. However, she noted diffuse joint pain that is chronic and unchanged.

With spacing and a little re-arrangement to keep similar ideas together:

A 60 year old female with a history of asthma, HTN, hypercholesterolemia, arthritis, and cholecystectomy comes in with SOB.

Symptoms feel similar to her asthma. She has wheezing, dry cough, and chest tightness with cough.

Exposure to smoke from a kitchen fire triggered her symptoms. Taking several doses of her albuterol inhaler improved her symptoms mildly.

She denied fever, palpitations, chest pain, abdominal pain, nausea, vomiting, and dizziness. However, she noted diffuse joint pain that is chronic and unchanged.

In this example, I’ve given each of the following their own small paragraph: the patient’s medical history, the sentences focusing on the asthma symptoms, the triggering/relieving factors, and a mini review of symptoms.

When we pay attention to our formatting, we can make a big difference in how easy our chart is to understand. Something as easy as hitting “Enter” 3 or 4 times improves the readability.

As you write your chart, consider how your chart will looks when you’re finished. Consider what is easy to read and what is difficult to read. Small changes can make a big difference.

If you’re interested in learning more about medical charting for clarity and medicolegal defensibility, check out my book, The Handbook of Medical Charting.