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Why Improved Patient Care Isn’t “In The Chart”

Why do we physicians chart the way we do? Hopefully, we do it perfectly well and have no concerns at all. But where I practice emergency medicine, we are approaching maximum inefficiency in charting.

It all became much clearer when we started using our new EMR system. Let me make it clear, I’m not against EMR. In fact, typing and templates work better for me than dictating. My dictations were usually a mine field of blanks and misunderstood words.

Furthermore, if I wanted to use it, we have a new voice recognition dictation system in addition to our templated chart. Though admittedly, the voice recognition program clearly hates some of my partners, as evidenced by the way they grasp the screen and yell at it (‘Chest Pain, not west rain!’) and by its inexplicable use of profanity in the occasional chart.

But I digress. The problem as I see it is the evolution of the medical record. Why does the medical record exist?

In the beginning, though I wasn’t there, I suspect it was really for one reason, and that reason was continuity. So that we would know what we had already done before we did something else. It’s why old docs had records that said things like: ‘Chief Complaint: Abdominal pain and vomiting. History: Pain began in upper abdomen yesterday. Today in right lower quadrant. Anorexic, vomiting. Exam: Abdomen shows tenderness in the right lower quadrant at McBurney’s Point. Guarding present, with rebound. Diagnosis: appendicitis. Dr. Surgeon was called and will see patient at hospital.’

By today’s standards, that’s a truly skeletal chart (probably fine for an orthopedist). Certainly not a chart you would want to take to court, nor one from which you could generate much of a bill.

Today, that same chart is more complicated by far, because it must contain pertinent negatives, a library of extraneous information and an almost entirely parallel universe of information, generated by the nursing staff.

Today’s emergency department chart, for our unfortunate victim of appendicitis, must include a Review of Systems that again addresses his abdomen, then asks about his head and neck, his breathing, his urination, his musculoskeletal system, his heart. Even if only to say, ‘all other systems negative.’ If not properly dotted and crossed, it will result in down-coding of the bill.

It has all of the nurses’ notes pulled over to the physician chart. This includes not only the allergy, medical history, medications, family history and social situation, but also the patient’s predilections for alcohol, drugs or tobacco. It also, as prompted by the nurses, asks about his nutrition, immunizations, and in the case of women, explores domestic violence concerns. Of course, the holy of holies, the pain scale, is also prominent on the nursing side. And at discharge, the nurses are tasked with medication reconciliation forms, to ensure that the patients take the right things at home and stop the wrong ones.

Time stamps and responses to therapy are noted, as are the times that physicians were paged, the times they called back and probably the time I left the bedside for the restroom.

The shiny, modern chart, at least in the emergency department, must also note that the nurse’s notes were reviewed — that we agreed with them or documented discrepencies. And what a thing to agree with!

You see, our nurses have to do their own detailed assessment. It includes their unique interpretation of the history (which the patient may change between professionals) and their own physical exam. And woe to you if your chart should exhibit an unmentioned discerpancy between physician and nurses’ charts’! You can hear the attorney now: ‘Doctor, the nurse felt this patient had rigidity and guarding, but you did not. Can you explain that?’ At which point you might have to suggest that your assessment was probably more reliable than that of the 22-year-old nurse who has only just graduated with her RN — a fact that the attorney will likely dispute.

Sadly, physicians and nurses alike are now slaves to the keyboard. Computer systems are overwhelmed with data. Discharge instructions, in order to keep up with the belief that ‘more is better,’ are the size of pulp fiction novels (with naughtier pictures).

I wonder, are our patients better off? Are we better clinicians now? Are we more compassionate? Are we faster? Are we more careful, or do we rely on the automatic to the detriment of the cerebral?

Evidence-based medicine seems to assume that a better computer system, or a longer chart, is always better. But what I want to know is this: now that the money has been invested, are we even willing to ask the question?

And would we be any worse off, lawyers and insurers and federal regulators aside, with the old hand-written chart, having just one or two paragraphs from start to finish? We won’t ever find out.

*This blog post was originally published at*

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