Spoken vs Written English - The Writing Exercise

This post is another writing exercise. We’ll be applying lessons I’ve shown you from previous posts (Omit Needless Words, Pay Attention to Your Formatting, and Written vs Spoken English) to a sample, fictional chart.

This post should be helpful to those who either use voice to text software or scribes who tend to transcribe verbatim.

Follow instructions as with the previous writing exercise posts:

1.       Copy and paste the sample to a word processor.

2.       Make your edits using the writing principles.

3.       Compare your answer to the possible answer at the bottom of the post.

I wrote the sample history of presenting illness as if I was dictating verbatim into a microphone. Here it is:

The patient is a 28 year old male with a history of obesity and asthma. He comes in today via EMS after a motor vehicle accident. He was the restrained driver in a motor vehicle accident where he rear ended the other car at what he estimated to be 15-20 miles per hour. He denied LOC. He denied head strike. He denied memory difficulty. He denied drug or alcohol use in the past 24 hours. He denied chest pain. He denied extremity pain. He denied dizziness. He said that he was distracted for a moment returning a text when the accident happened. He said the front end of his car “was totaled”. He said he was able to walk afterwards. EMS report confirms that he was ambulatory at the scene. EMS report also confirms extensive damage to the front of his car.

This may work well for spoke English, but it’s poor written English. It’s a jumble that we can clean up with a little bit of work.

Work on it and then scroll down. I've shown you one path (certainly others exist) to a more efficiently-written version of this HPI. 

First, let’s pare the HPI down to essential words. I’ll highlight what’s (arguably) needless. Repetition is an easy first target for cutting out needless words. What words does the story need to drive itself forward?

The patient is a 28 year old male with a history of obesity and asthma. He comes in today via EMS after a motor vehicle accident. He was the restrained driver in a motor vehicle accident where he rear ended the other car at what he estimated to be 15-20 miles per hour. He denied LOC. He denied head strike. He denied memory difficulty. He denied drug or alcohol use in the past 24 hours. He denied chest pain. He denied extremity pain. He denied dizziness. He said that he was distracted for a moment returning a text when the accident happened. He said the front end of his car “was totaled”. He said he was able to walk afterwards. EMS report confirms that he was ambulatory at the scene. EMS report also confirms extensive damage to the front of his car.

 

 Now with some needless words taken out:

A 28 year old male with a history of obesity and asthma comes in via EMS after a motor vehicle accident. He was the restrained driver where he rear ended the other car at what he estimated to be 15-20 miles per hour. He denied LOC, head strike, memory difficulty, drug or alcohol use in the past 24 hours, chest pain, extremity pain, dizziness. He was distracted for a moment returning a text when the accident happened. He said the front end of his car “was totaled”. He was able to walk afterwards. EMS report confirms that he was ambulatory at the scene and extensive damage to the front of his car.

 

We’ve tightened our HPI up a little bit. Now let’s format it by separating out some logical sections.

One section could be a chief complaint with a little bit of context. Another section could be a review of pertinent systems. Yet another section could be confirmatory information from EMS.

I’ll highlight them in different colors and then separate them.

A 28 year old male with a history of obesity and asthma comes in via EMS after a motor vehicle accident. He was the restrained driver where he rear ended the other car at what he estimated to be 15-20 miles per hour. He denied LOC, head strike, memory difficulty, drug or alcohol use in the past 24 hours, chest pain, extremity pain, dizziness. He was distracted for a moment returning a text when the accident happened. He said the front end of his car “was totaled”. He was able to walk afterwards. EMS report confirms that he was ambulatory at the scene and extensive damage to the front of his car.

Our answer:

A 28 year old male with a history of obesity and asthma comes in via EMS after a motor vehicle accident. He was the restrained driver where he rear ended the other car at what he estimated to be 15-20 miles per hour. He was distracted for a moment returning a text when the accident happened. He said the front end of his car “was totaled”.

He denied LOC, head strike, memory difficulty, drug or alcohol use in the past 24 hours, chest pain, extremity pain, dizziness. He was able to walk afterwards.

EMS report confirms that he was ambulatory at the scene and extensive damage to the front of his car.

Now it’s much easier to read.

Are there other ways to separate and organize the information? Yes, but this is just to demonstrate the process. Each person will use these tools a little bit differently.

The important concepts to remember are to omit the needless words and to organize your thoughts in a logical manner on the screen.

To learn more about clear and effective communication in medical charting, please check out my book: The Handbook of Medical Charting

Written vs Spoken English

Should I write the same way I speak?

No.

Written and spoken English are different dialects of the English language. Yes, both are still English, but what works well for one is not necessarily work well for the other.

This applies to writing in general, and also applies to writing a medical chart.

Some examples of the differences between spoken and written English are in the lists below.

Spoken	Written
Tone	No equivalent
Timing	Uses punctuation instead
Rhythm	Uses punctuation instead
Inflection	No equivalent
Volume	No equivalent

Imagine reading a move script in your mind vs hearing it read out loud by good actors. It’s a world of difference. Spoken language is rich with other cues beyond the words themselves.

Good writing is not necessarily good speaking and vice versa. Good writing is typically more brief, terse, and direct. When reading good writing out loud, a listener may not catch every idea in a sentence in written English simply because of the brevity. The extra words themselves can give your listener an extra moment to process what you’re saying. When a reader is looking at the words on paper, these extra words are not necessary. In fact, the extra words get in the way.

Let’s look at these examples:

Spoken

I did read the CT scan of the chest. It showed no pulmonary embolism, but did show a left lower lobe pneumonia.

Written

CT read showed left lower lobe pneumonia. No PE.

The written version is shorter, and more compact. Writing allows the use of abbreviations and acronyms to make it more compact. When spoken out loud, the shorter sentence gives the listener less time to process the information.

Writing is refined thinking. The writer has to consider what words to use, and how to place the words in an efficient, coherent way. More mental processing goes into writing than goes into speaking. Speaking is natural. Writing is not. Writing gives you more opportunity to refine the end product than speaking, because you have to think more when you write

A good example of this is a dictated chart. When you do not take the conscious step of extra editing, your dictated chart will tend to ramble. It can look like a stream of consciousness. This is bad written communication. It’s much more difficult to read and understand.

You are also more likely to say accidentally something that you don’t intend to say.

Spoken (I dictated this to myself without editing)

The patient is a 25 year old female with a medical history of asthma. She came into the ER with accessory muscle use, shortness of breath, wheezing and said that this was consistent with asthma attacks she had in the past. She denied recent steroid use, and previous ICU admission. However, she said that she had a admission for asthma about 6 months ago. Her last steroid use was about 2 months ago, that she received from her primary doctor. Preceding symptoms include uri symptoms such as runny nose, sneezing, and dry cough. Overall, she had the asthma symptoms for about 2 days that are gradually worsening and the preceding uri syptoms for about 2 days as well.

Written

25 year old female asthmatic. She came into the ER with 2 days of symptoms consistent with asthma attack, including accessory muscle use, shortness of breath, and wheezing. No recent steroid use, or previous ICU admission. Most recent admission for asthma about was 6 months ago. Most recent steroid use about 2 months ago. Preceding symptoms include 2 days of runny nose, sneezing, and dry cough.

The written version is more compact, direct, better organized, easier read, and overall better communication. The directly transcribed spoken version comes across as a rambling, scattered stream of consciousness. The directly transcribed, spoken is worse communication by far.

If you’re going to use dictation, be sure that you put some thought into the words you are dictating. You should take the extra step and edit your words (either mentally or on the computer screen). You are translating from one dialect into another. Take the extra mental steps for that translation before you speak so that your charts aren’t rambling. Use the words in your mind and craft them in a way that is efficient.

If you are working with a scribe, make sure that the scribe knows that they should not transcribe word for word unless you are going to heavily edit the chart later. The scribe has to translate from spoken English to written English.

Either way remember to take the perspective of the reader. What will be easier for them to understand? Take these concepts into account and your dictations will get better.

To learn more about effective medical charting, check out my Handbook of Medical Charting

My History and Physical are Tests Too!

Patients seem to love tests. I guess people love the technology. Maybe there’s the allure of something shiny, mysterious, cold and alien. Maybe it’s the trust in something shiny, mysterious, cold, and alien over the all-too-familiar, warm flesh and blood. Clinicians are just humans too, like patients… so how could they possibly know things the patient hasn’t deduced themself?

Even a junior clinician who has reached a simple diagnosis through their history and physical has heard the patients say something like, “But how do you know? You didn’t do any tests?” What the patient does not realize is that the history and physical exam are tests as well. The palpation of the abdomen, the inspection of a person’s gait, the travel history, the color of the stool, the frequency of symptoms, etc. are all tests in themselves. However, they are something that seemingly any other person could do... and you the clinician are just flesh and blood doing these relatively simple things.

Getting diagnosis can be like detective work. We think highly of fictional detectives who solve the crime by paying attention to the subtle, sometimes-under-your-nose details that others miss. It’s amazing  reading about detectives who are able to solve a crime by weaving a cohesive picture by seeing deeper into the mundane details that at first seem unimportant… that is until the detective puts the pieces together. So why is it the opposite of amazing when a clinician does something similar and finds the culprit through collecting simple clues and deductive reasoning?

The history, physical, and tests are just data gathering. These are data gathering tools to bring the clues into a cohesive picture together, like a detective trying to solve a crime. All of these have statistical aspects: sensitivity, specificity, false positive rate, and false negative rate. All are pretty good in the right circumstances and all are flawed.  

Often we consider the sensitivity, specificity, etc. exclusively when we are talking about data we obtain through technology. As a clinician gains experience, they realize that their history and physical exam have the same characteristics as well. Many times this realization is intuitive, not explicit.

For example in the case of acute appendicitis, a CT scan certainly has a measurable sensitivity, and specificity. A small, older study I found says both the sensitivity and specificity are around 90%. Another small, older study found that the sensitivity of rebound tenderness was 94%.

For a more recent example, this study showed evidence that for vertebra-basilar strokes the HINTS exam was more sensitive than MRI. The study showed HINTS was 100% sensitive.

Putting the potential flaws of these studies aside, the point is that we should treat the data we obtain via history and physical examination just as we would treat data we get from a machine. Whether from a history and physical or measurements from a machine, we can assess the statistical aspects of the data we collect.

Data is still just data regardless of its source and it will have its appropriate weight in the patient’s overall picture.

So whenever you question whether your history and physical are enough, and question if you need to do tests, remember that your history and physical exam are tests too.

I discuss this topic and more in my upcoming book on clinical decision making. I expect it to be coming out later this year.

Data vs Information

The late business management expert, Peter Drucker, wrote that information is data given relevance and purpose. Although he wrote about a different industry, this concept is useful for us in clinical medicine.

We can apply this concept in our communication with others in the clinical realm. How exactly can we do that? I’ll show you three, related concepts with an example for each.

The three concepts are

1.       Putting data into a context

2.      Leading with our assessment

3.      Taking the listener’s perspective

We have to put data into a context. Without context, without a bigger picture, an isolated fact your receive has little meaning, less actionable information.

You could write:

      The patient is a 3 year old with a  fever of 39 degrees Celcius.

Without the context, this bit of data means little. With a little bit more, well-selected data, you can have a clear picture of what is going on.

The patient is a 3 year old with a fever of 39 degrees Celcius. He is drowsy, has poor capillary refill, and sunken eyes.

In contrast

The patient is a 3 year old with a fever of 39 degrees Celcius. He is alert, smiling, and drinking juice vigorously.

I’ve only added 3 new facts with each sentence and the clinical picture is very different for each scenario. The first child sounds like he’s potentially very sick. The second child sounds like he’s got mild illness. A little context makes a huge difference to your audience’s understanding of the situation.

We can lead with our assessment, with our conclusion. Sometimes giving our conclusion first, then putting our data into that context is most efficient for communication.

You could tell a colleague:

The patient is a 48 year old female with frontal headache, constant in nature, worse with moving her head, associated with dizziness and nausea. No vomiting. Cranial nerves 2-12 are intact, 5/5 strength in all 4 extremities, normal gait. Neck supple. Bilateral sinus tenderness, and moderate amount of purulent mucous in bilateral nares. I think it’s a sinus headache.

           

            Alternatively, when you lead with your conclusion:

I think this patient has a sinus headache. She’s a 48 year old female with frontal headache, constant in nature, worse with moving hear head, associated with dizziness and nausea. No vomiting. Cranial nerves 2-12 are intact, 5/5 strength in all 4 extremities, normal gait. Neck supple. Bilateral sinus tenderness, and moderate amount of purulent mucous in bilateral nares.

True, in the classic teaching in medicine, you shouldn’t trust anyone else’s evaluation and you should re-evaluate the patient yourself. However, when you lead with your conclusion your audience at least have an idea of what you are trying to communicate. Give your listener the context of your conclusion, which they can go and test for themselves. You don’t leave the other person to figure out what you’re to tell them until the end and then have them mentally go back and try to see if all the facts you told them fit. Instead, you’re telling them, “This is my conclusion, here’s an opportunity to reference that conclusion against the pertinent facts I’ve collected.”

Another example is that we take the listener’s perspective. We have to consider what is useful for them. In clinical medicine we talk to different people who have different roles to play in the patient’s care. Take a moment and ask yourself, “What is my listener’s role in this patient’s care? What do they need to know?”

A nurse brings a patient to the general, inpatient unit and tells the hospitalist, “The new patient with the recurrent seizures just came from the ER.” Supposed the nurse stops and looks at the hospitalist for instructions.

Most likely the hospitalist needs information before their next action. The nurse gave facts not actionable information.  Should the hospitalist stay in their chair and continue the work in front of them? Should they get up and see this new patient immediately? Who knows? Adding a little extra information helps tremendously.

            Here’s a little extra data with actionable information:

“The new patient with the recurrent seizures just came from the ER. He got a lot of valium downstairs and is a little groggy, but seems pretty stable.”

Alternatively…

“The new patient with the recurrent seizures just came from the ER. He got a lot of valium downstairs and looks like he’s having problems breathing.”

           

The patient in the second description probably needs an urgent assessment, the one in the first likely can wait. Now the hospitalist knows what actions to take, and a few extra seconds worth of speaking gave that information.

Sadly I think many of us in clinical practice see some kind of poor communication at work on a regular basis. The above are just three examples, but with paying a little bit of attention, I think most clinicians could list several more.

Take these lessons into account whenever you communicate with someone else clinically. As we’ve seen, you can do this both in writing and speaking. Make the data into information, make it relevant and useful.

If you’re interested in further discussion of information vs data in the clinical realm, please keep an eye out for my upcoming book, A Guide to Clinical Decision Making.

Pay Attention to Your Format - The Writing Exercise

In the spirit of active learning, I’m posting another sample exercise. Actively implementing a concept solidifies your understanding of it better than passively reading about it.

This post will focus on how to format a chart to make it easier to read. We discussed this in an earlier post: Pay Attention to Your Format.

Like the previous post, Omit Needless Words - The Writing Exercise, this will be a good exercise to solidify a writing concept.

There are 2 basic concepts to remember with formatting your chart:

            1. separate different ideas

2. lump similar ideas together

Remember that this functionally means use paragraphs.

As in the previous exercise blog, you will:

1.       Copy and paste the HPI onto the format of your choice

2.       Make paragraphs

3.       Compare to the “answers” at the end.

As with the Omit Needless Words exercise, there may be more than one way to format the sample, fictional HPI. Remember that this is more closely related to the art of medicine than the science of medicine. As in clinical medicine, often we have more than one reasonable way to address a problem.

Please pass this on to colleagues, residents, medical students, PA students, NP students, and scribes. I think many people will find these exercises useful to sharpen the clarity of their charting.

The Sample HPI:

56 year old male with a history of gastritis, HTN, and cholecystectomy. Takes PPI daily. He comes in with 3 days of nausea, vomiting, diarrhea, and epigastric pain. No blood in his diarrhea. About 3 episodes of diarrhea daily. Small streaks of blood in his vomitus today. About 6 episodes of vomiting daily. Symptoms started after eating fried fish. Mild, transient improvement after taking his PPI. Has poor appetite, generalized weakness, dizziness on standing, and generalized body aches. No fever, runny nose, nasal congestion,  headache, dysuria, skin color changes, chest pain, cough, syncope, or episodes of confusion.

One possible answer:

56 year old male with a history of gastritis, HTN, and cholecystectomy. Takes PPI daily.

He comes in with 3 days of nausea, vomiting, diarrhea, and epigastric pain. No blood in his diarrhea. About 3 episodes of diarrhea daily. Small streaks of blood in his vomitus today. About 6 episodes of vomiting daily. Symptoms started after eating fried fish.

Mild, transient improvement after taking his PPI.

Has poor appetite, generalized weakness, dizziness on standing, and generalized body aches.

No fever, runny nose, nasal congestion,  headache, dysuria, skin color changes, chest pain, cough, syncope, or episodes of confusion.

With this answer, I’ve made different sections to this HPI separating his medical history, presenting symptoms, inciting factor, positive ROS, and negative ROS. Each section communicates separate, aspects of the history. When your readers see a different section, they know that you are going to talk about a different aspect of the case.

Another possible answer:

56 year old male with a history of gastritis, HTN, and cholecystectomy. Takes PPI daily.

He comes in with 3 days of nausea, vomiting, diarrhea, and epigastric pain.

Small streaks of blood in his vomitus today. About 6 episodes of vomiting daily. No blood in his diarrhea. About 3 episodes of diarrhea daily. Has poor appetite, generalized weakness, dizziness on standing, and generalized body aches.

Symptoms started after eating fried fish. Mild, transient improvement after taking his PPI.

No fever, runny nose, nasal congestion,  headache, dysuria, skin color changes, chest pain, cough, syncope, or episodes of confusion.

With this possible answer, I’ve re-arranged some of the sentences. I’ve grouped the further description of the GI symptoms with the positive ROS, to illustrate the severity of the symptoms. I’ve grouped inciting and improving factors into one separate section. Finally, I’ve separated the negative ROS information.

I hope you found this a useful exercise to sharpen your chart writing.

To learn more about clarity in writing your own medical charts, please check out other posts on this blog, and my book, The Handbook of Medical Charting.