After 40 minutes in line, six of us dragged our stuff to the constipated customs agent. “You did not complete this form correctly. The address is blank. Go fill it out correctly”, he said without breaking his scowl.
“We rented a farm house in Sheffield,” my wife said. “We will call when we get close so the landlord can guide us to the property.”
“You need to fill in the exact address,” he said, still frowning. “Go stand over there and fill in the address.”
Ah, the joys of dealing with a chart-filler after being up all night on a sold-out charter…
Medical Records, Not Patients
We do the same in medicine. Medical records demand as much work as patients, sometimes more. Providers soon learn that detailed notes offer the best protection in court regardless of what happened in real life.
We force patients to provide answers:
“When did it start hurting?”
“Have you ever experienced this before?”
“I don’t know,” is not an answer. Patients must do better; we need to fill in our forms.
We force patients to run our medical records gauntlet after they’ve been writhing in pain all night. We believe that charts improve care.
A group of us reviewed an integrated care plan for medically complex patients last week. It was utopian: spots for every possible allied health provider, boxes for lifestyle issues and social determinants of health, room for every possible past medical concern, and a ton more all in a few dozen pages.
Our medical records Frankenstein cannot be put back in the womb. It can only get bigger, and scarier.
Inevitably, we use standardized charts, cut and paste. Just listen to a surgeon dictate a note for an uncomplicated appendectomy. Other than the patient’s name, it sounds almost identical to any other.
Does a long, officious chart add value for an individual patient? Do one or two unique details buried in pages boiler plate benefit patients, or providers?
Lawyers, bureaucrats, and health coders love long charts that miss nothing. But do they add value for patients?
(photocredit: boomersinfokiosk.blogspot.com)
Shawn…as you well point out…docs need to find an optimum level of listening to patient and recording ALL pertinent info.
Problem as I see it:
The recent travel insurance client medical claim denials raises the questions of any record input that even seems to question a possible medical problem even if no treatment was ever implemented is cause for denial by insurers. It appears that the travel medical insurance application would be best completed by the doctor, who I suspect, has no time to complete these forms.
Why…..patient doesn’t know everything in their file which can cause denial. The medical world and the insurance world appear to be headed for a clash of what’s on record and if that info was actually a real medical problem or doc saying it might become one.
The insurer should actually give us patients that have been treated for a condition and are stable with special rates….they know who they’re insuring where others could be a ticking medical time bomb.
You raise an important point, Don!
You touch on relevance, confidentiality, purpose of medical records, and more. This is a huge issue, and more do not know how fast things are changing around them.
Thanks for reading and commenting!
Shawn
I have to disagree with this partially. Emergency records are woefully inadequate and in fact should be very detailed as they deal with high risk patients. I had an elderly lady come in with hyponatremic seizures and looked at the old record for help before I knew what was going on. She was in 2 days ago. I could not read anything on the chart. It is no wonder that emergency physicians are sometimes devalued as one assumes the quality of documentation relates to the quality of care. We also need good documentation for lawsuits. The rule of law is important for good care. Physicians and really everyone in society needs to be checked. Try getting medicine in a country where physicians are not checked and the care is worse. The threat of lawsuits improves documentation. Improved documentation improves care both at point of care and also in case reviews where there was an adverse outcome where you can see what went wrong and how to change it in the future.
As always, you offer a great comment, Scotty!
I agree 100%: ED charts with a few illegible lines do nothing for patient care, make EPs look unprofessional, and do not stand up in court. I also agree that audit and oversight keep us sharp.
When I wrote this post, I had in mind the multi-part forms with little boxes for every answer. I’m sure you’ve experienced trying to answer surveys that do not have your response as one of the options (and no text box for a free-form answer). The complex patients’ form we reviewed would have made the most astute, data-loving emergency physician crazy! It would require a solid 25-30 minutes to read over.
There’s always a balance between a 4 page, single spaced consult note from a internal medicine PGY2 and a 2 line note from a staff orthopod.
I worry about forcing patient answers into boxes that meet providers’ needs and notes that are 4 pages but contain the same amount of unique details as the 2 line ortho note. Thanks for helping me clarify!
Great having you read and comment!
Best
Shawn
Perhaps the issue is the increased complexity of medicine rather than the EMR flight-like check list which “would require a solid 25-30 minutes to read over.” Is 25-30 min too much time to spend reviewing the past health record of a 50 year old patient in distress? Maybe we could be better medical detectives by reviewing histories and ordering tests intelligently rather than treating everyone as if they had exactly the same risk for every disease as other people, or worse, making snap judgement of the diagnosis within 50 minutes of seeing the patient. If, as we both probably think, such time leisure is impractical, maybe the issue is under staffing and customer overbooking that is the real problem, not EMR/EHR’s. EMR’s can provide useful documentation and electronic ones can provide useful checklists to avoid overlooking things IF created thoughtfully and completed accurately. That’s a big IF. I don’t believe half of the copy-pasted EMR notes I read. Some EMR’s are inconsistent within a single record (e.g. no family history of melanoma, positive family history of melanoma).
Great comment, Dell!
I agree. EMRs make my life easier in so many ways. I do not have a problem with EMRs per se. I challenge the motivation behind creating pretty charts. I’ve heard that, in the olden days, you could get away with writing: “AOM. Rx Amox”. Today, you need several paragraphs documenting all the reasons why this patient does not have meningitis, bacterial esophagitis, retropharyngeal abscess, pneumonia and basically any other upper respiratory disease than a simple, uncomplicated acute middle ear infection. Charting to say what’s not there benefits us, not patients, and buries the 1 or 2 important details in a pile of compost.
You make a great point about inconsistent details. When we actually start tearing apart these beautiful, comprehensive charts, they often fail to tell the story. We still need to hear a narrative from the physician.
I do not see an easy answer to this issue. I only raise it to say that patient benefit from charting seems overshadowed by the need to meet regulations and preventative medico-legal protection.
Thanks so much for taking time to read and comment! Brilliant!
Best,
Shawn