There has always been a disconnect for practitioners between doing what they do and then writing about it in the patient’s chart. This was true when we had paper charts, and the advent of EHR (electronic health records) has made the separation even wider. When my notes were on paper, written longhand, I often got compliments from other practitioners. They found my notes to be clear, concise, and helpful in orienting them to what my plan was, and to what was going on with the patient.
Paper Versus Electronic Note
E-notes tend to be long because they’re inclusive. Prior history, problem list, vital signs, fluid intake, labs, x-ray reports, medication lists can all easily be pulled into a note. This is precisely what makes them so unfocused and useless for emphasizing what the note writer thinks is really important.
Even skipping to the bottom to read the impression and plan is not helpful if it is merely cut and pasted from the day before, or worse, cut and pasted from another practitioner’s note. What I liked about writing notes on paper was that they told a serial story about the patient. It’s hard to include a patient’s unique qualities into an electronic note. It takes some creativity.
As a writer, I’ve come to recognize my creative process, and yes, I extend creativity to include the writing of progress notes. I like to reserve the right to revise and edit. There’s something so final about clicking the Sign, or Send, or Submit button. That’s why I don’t write my notes at the same time that I’m seeing the patient, even though it would be much more efficient.
While it’s possible to write or dictate a note during a patient encounter, my cultivation of mindfulness has given me a distaste for this type of multitasking, especially if my attention is on the computer screen instead of on the patient. The few lines of the HPI (history of the present illness) have become my vehicle to transmit the patient’s unique qualities and her narrative. I don’t want to feel rushed as I put those words on paper.
Paper Versus Conversation
The disconnect between documenting and doing is not always clear to doctors though. The term “informed consent” usually refers to the piece of paper that the patient or her proxy signs to give permission for a procedure. The term is supposed to refer to the conversation that explains the risks, benefits, and alternatives to the procedure for the patient.
In a similar paper-versus-conversation confusion, an ambulatory case manager emailed me to ask if a physician could fill out a POLST form without the patient present. She wanted to know if there was a requirement that the conversation be face to face. At first, I didn’t know how to respond to this email.
First of all, it’s the patient’s POLST form, not the physician’s. Secondly, it’s meant to document the conversation that the practitioner and the patient have together. Both signatures are supposed to be at the bottom to finalize the document.
Now, I know in this age of texting that conversations can be dyssynchronous. Many times my son will message me at midnight after I’ve gone to bed, and I’ll reply at 4 am before he gets up. But even if POLST regulations have not allowed for technology innovations such as Skype or FaceTime between practitioner and patient, I’m still disturbed by the question the case manager is asking.
As part of the ethics committee, I’ve learned of abuses of advanced directives in institutions. When residents who can’t make decisions have no known next of kin, a guardian is supposed to be assigned. Institutional staff cannot unilaterally make decisions regarding the care of their patients.
A commonly bandied phrase in medicine is “If it isn’t documented, it isn’t done.” This is a phrase that billers and coders love. Appropriate documentation, with its checklist of required components, is necessary to justify billing levels of service for Medicare and other insurers. The danger, though, is when this is taken to such an extreme that things are documented instead of done, as in the case of filling out a form on behalf of a patient without having a physical or virtual conversation.
How do you balance the demands of the EHR with your need to interact with patients? Do you save documentation for after hours, affecting your work-life balance, or do you prioritize efficiency to allow more time with family?
Great topic.
An EMR is a tool that is intended to facilitate attaining a goal. However, since EMRs were not designed solely by providers or patients, sometimes it can be an ill-designed tool, and the goal that it is attaining is not entirely clear. Once again, the input of those on the front lines, receiving the care and writing and reading the notes is essential. We must advocate for this if we hope to have meaningful documentation.
P.S.I write my notes after office hours, for the same reasons you mention.
I agree totally with the impersonal-ness of the EMR. I have navigated the chart for several Joint Commission surveys and we struggle to understand the whole picture. Usually, it’s the nurse that has bonded with the patient who provides this information. I have an example: A 37 year old African American man was admitted to our unit for SOB and Sickle Cell crisis. His chart listed his medical history which included IVDA ( IV drug abuse). Sadly the patient coded and passed away and it wasn’t till the next day, when I met his mother that the whole story of his sad life was explained to us. He was in constant pain and suffered all his life with an inherited illness and his pain needs were not met. He turned to illicit drugs to treat his pain. How sad that this was not in his medical record. His mother was at peace with his death because he was no longer suffering. I feel he was misjudged all his life.
Yes, I agree with you that with EHRs, the need for narrative medicine has gone way up. There is no record of the patient’s experience of his illness. Dr. Rita Charon at Columbia regularly leads workshops to help healthcare providers learn and teach these narrative skills. Narrative medicine enhances the patient’s experience as well as the providers’ own fulfillment.