Docs spend more time with electronic health records than with patients. Many blame electronics. True, bad systems eat hours of nurse and physician time, but the biggest waste is fat charts.
If bigger is better for patient charts, then medical students make the best charts; staff physicians the worst.
Every year, trainees get better at sharpening details. Expertise leads to focus on critical information: everything that does not add value gets left out. Charts get shorter…until providers start padding charts for other reasons.
Modern patient charts aren’t just about patients.
Charts get longer to:
1. Protect against Lawsuit:
A long chart makes it tough to prove providers weren’t thorough. You can prove you thought about all sorts of things by listing all the negative responses you found even though the negatives don’t help the patient.
2. Protect against audit from your regulatory college:
The overseers/authorities/police believe they know what makes a great chart. They support #1 above and enforce it, and they (groups of lawyers and lay-people mostly) define ‘best practice’.
3. Protect against billing audit:
Long charts look like lots of work was done.
Value Added?
Would an informed patient willingly pay for long notes that were created to protect providers?
Do long lists of ‘pertinent negatives’ add anything for patients? Sure, they ‘prove’ providers considered a differential diagnosis, but considering a differential diagnosis is core medical practice; why should they prove they did it?
The whole medical decision-making heuristic rests on a differential diagnosis approach; why prove it over and over on every single chart?
As a provider, if you just wrote the diagnosis, does that mean you suddenly became anti-differential diagnosis? Even if you recorded pages of negative findings and came up with the wrong diagnosis, does that help the patient any more than just writing the wrong diagnosis in the first place? All it proves is that you were thoughtfully wrong.
Two types of Complaints
A. You know what’s going on:
This chart needs positive historical points and physical findings, diagnosis, and treatment. That’s it. Nothing else adds value for the patient.
B. You have no clue what’s going on:
This chart needs more. You should write a book: everything you thought about and why it doesn’t fit. In fact, long charts define clinical uncertainty, not clinical excellence.
If patient charts should be about patients, we need to:
1. Change expectations:
Focus only on what adds value for patients.
2. Change charts:
The whole process could be done with macros and tick-boxes. Only critical findings (positives, diagnosis, treatment plan) need manual entry.
When physicians and nurses go back to review a chart, they NEVER need all the information in it. NO ONE DOES, except non-providers! Clinicians look at old charts to find 1-2 critical pieces of information that have meaning for their patient.
How short would your chart be if you weren’t worried about lawsuits and audits? What needs to be in the chart if only patient benefit mattered?