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.

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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.”

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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.

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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?”

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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

 

Dictating Your Charts: A Crash Course

 

Dictating your charts can be an effective way to write your charts if you know what you are doing.

If you do not know what you are doing, your charts are likely to be disorganized, rambling masses of words that your readers cannot make sense of.

Depending on what your charting system allows, you may have the option to dictate all or part of your chart.

A few key concepts will hold true regardless of whether you dictate all or part of your chart:

• Dictate purposefully
• Spoken language is different than written language
• Keep your goal in mind
• Stay organized
• Use a few written notes
• Proofread

Some of these concepts are related and some build on each other.

Dictate Purposefully

Becoming proficient at dictating can only come with practice. Just reading this article or a similar one will not make you good at dictating. You must practice dictating to become good at it.

However, dictating a lot without keeping certain guidepost principles in mind will most likely not make you proficient, it will instead help you develop bad habits.

This crash course will give you some guiding principles to keep in mind as you dictate. If you use these principles purposefully when you dictate, your dictations skills will improve quickly.

Spoken Language is Different Than Written Language    

We can write the way we naturally talk. However, it is not efficient. Think of written and spoken language as 2 different dialects of the same language.

To dictate well, you should translate your spoken language into written language.

Typically, spoken word relies on cadence, tone, rhythm, and other nonverbal cues. Written word does not have these.

Spoken word put in writing is also longer because it often depends on the passive voice and repetition. Written language needs fewer words to convey the same idea because, the reader has the opportunity to re-read, pause, and digest what you are trying to communicate.

Rules and tips for good writing are beyond the scope of this crash course, but you can find these easily.

Keep Your Goal in Mind

 Your goal is what you are trying to communicate. For example: My patient has pneumonia and is safe to go home or My patient has pneumonia and is sick enough to be admitted.

This sounds basic. However, it is easy to lose your focus and get off track when you are dictating. 

One explanation for why you can lose track is that you can talk more quickly than you can think. In essence, your mind cannot keep up with your mouth. Contrast this with when you write. Writing is generally slower than speaking and you have more time to process your thoughts.

Another explanation is that you can get lost in the details of the chart. Losing the proverbial forest for the trees.

When dictating, slow down a bit and focus your dictating on details that further your goal.

Stay Organized

It is easy to dictate a disorganized chart. So be mindful to stay organized.

Written charting often has built in forms for you to fill out. Depending on the medical record system you are using, you may or may not have these.

If your system is more free text, you will have to make your own, mental template. For such a template, have a standard, personalized order of how you will present the information. For example, in a review of systems, you should try to present organ systems in the same order every time. Your physical exam, and assessment and plan should similarly have the same template.

Training yourself to use the same template increases the chance of your chart being complete. 

One trap you can fall into using the same template every time is that you do not customize it to your patient. In these cases, you are dictating out of reflex. This is the same trap you can fall into using written templates. To minimize this, slow down when you dictate, and keep your goal in mind.

Use Handwritten Notes

Handwritten notes are obviously a memory aid. However, having a few, handwritten notes also can help focus your mind during dictation.

If you dictate your patient cases in batches, using notes can be very effective in helping you remember the details. Your handwritten notes should not be lengthy, but should contain a few key elements in your patient’s case. Try to keep your handwritten notes focused on what makes this patient unique.

Proofread

Once you are finished dictating your chart, read through it and ask yourself, “Does this chart say what I want it to say?”. This is universal advice for anytime you write something.

The most practical time to do this will probably be once you finish dictating. However, you are likely to catch more mistakes if you proofread later in the shift, even at the end. Your mind will approach the chart with a more “fresh eyes”. This is analogous to someone writing an article, coming back to it a couple days later, and making better self edits than if they proofread immediately after they wrote the article. When your mind has some distance away from the chart, you can take this outside perspective more easily. Your mind is less likely to automatically fill in the gaps that are in the story that is in your chart.

As mentioned earlier these are tools for you to use while you dictate to help you become more proficient. Reading this alone cannot make you proficient, you have to practice by dictating purposefully and thoughtfully.

If you are interested in learning more about medical documentation, you can also check out my book: The Handbook of Medical Charting