Sunday, December 4, 2011

Making Medical Chart Notes Less Terrible

During my own residency in Greeley, one of the hospital's pulmonologists wrote notes in the hospital chart that were a delight to read. Yes, you read that correctly. His documentation IN THE HOSPITAL CHART was not only legible, but downright literary. It was not unusual to actually FEEL something when reading his chart notes--to chuckle at a patient's quirks, or to feel empathy, or to be seduced by the mystery of the diagnosis.

I have not seen anyone write notes like this since.

Now, with the rise of electronic medical records (EMR), our charting is usually done with computers. I am no Luddite. Electronic medical records have many benefits, including ability to extract and track data, reminders that improve care and templates that (sometimes) speed documentation. However, EMR has also devastated the readability of clinical notes. Every physician has tried to read a note generated by a colleague with an EMR, only to find a frustrating, poorly formatted jungle of lists, irrelevancies, incomplete sentences and poor (if any) punctuation.

But it doesn't have to be this way! Physicians should utilize the spectrum of benefits that follow from higher education, including the ability to think and write more clearly. Our notes can be scientifically accurate and readable, clinical and literate, informative and sophisticated. In the spirit of reversing the trend I've seen toward clinical documentation nearly indistinguishable from text messages, I offer the following remedies adapted from the classic book on quality writing, The Elements of Style by Strunk and White.

1. Use the active voice. Chart notes are frequently blighted by passive phrasing such as: "The cough was noted by the patient to become productive," or "the reason the patient increased her smoking was due to job stress." Not only is the active voice a stronger, more lively way to write, it is usually shorter and therefore more efficient! "The cough became productive." "Job stress prompted heavier smoking." Concise, complete sentences still say the same thing.

2. Put statements in a positive form. Another scourge of medical writing is the dreaded "the patient denies" some symptom or other. Oh, really? Is the patient accused? ("The patient endorses" is no better.) Why not say, as the skilled editors of the New England Journal of Medicine's case reports do, "She had no cough, dyspnea or hemoptysis"? Period. We know it is the patient we're reading about, after all.

3. Use definite, specific, concrete language. I often jokingly remind residents to "use your words." Medical language, like all scientific language, is ideally very specific and economical. "Having trouble breathing" can mean several things. "Dyspnea" is specific, and different than "wheezing" or "orthopnea." "Spitting up blood" can mean "hematemesis" or "hemoptysis" or even "posterior epistaxis." "Fatigue" may mean "sleepiness" or "weakness" or "abulia" or "lassitude." Use the most specific word that fits, and get a thesaurus app if you need one.

4. Omit needless words. Using more words makes the writer sound, not smarter, but more confused and confusing. "The chest pain is secondary to ischemia" should become "This is ischemic chest pain." "This is a patient with cirrhosis and pneumonia" becomes "He has cirrhosis and pneumonia." Simpler is almost always clearer.

5. Expand your vocabulary. Medical students are trained to write certain phrases and cliches while learning the basics of charting. Many of us, though, never move beyond this. Where is the holy writ that says we must write that a patient is "well-developed and well-nourished" (WD/WN) instead of muscular, brawny, sturdy, heavyset, corpulent (whichever applies)? Why must we use "disheveled"? Can the patient not also be unkempt, bedraggled, rumpled, even slovenly? Are patients only "pleasant"? No doubt we also see patients who are amusing, delightful, charming, joyful, genial, cordial, well-mannered.

The literate pulmonologist whose notes I so enjoyed reading was not following a list of rules, of course. I suspect he had simply mastered a core principle of good writing: write with the reader in mind. Unfortunately, as medical students we write lengthy discourses that no one ever reads, which teaches us to write, not to communicate, but simply to "document." It is high time to recover the skill of writing clinical notes to be read, not by hypothetical lawyers in some feared future courtroom, but by colleagues whom we can inform while simultaneously engaging in the patient's narrative.

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